The Fate of Borderline Pathology in Dimensional Classification Systems: A Narrative Review
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThis narrative review followed the development of the borderline personality disorder diagnosis, the move to dimensional models of personality disorders, and examined the nosological status and clinical utility of the borderline construct going forward. The review was well written and highlighted a congruence between the borderline concept and current dimensional models that is an important addition to the literature. The authors should consider the following:
1. In the section on Level of Personality Functioning, the authors referred to a “regional tradition” but did not make clear what was meant by this phrase.
2. On page 5, the authors introduced the “TAT” but did not define this acronym.
3. On page 6, the authors indicated that “regression proneness” is an important feature of borderline pathology but suggested that regression only occurs “under the pressure of affective disorder”. This conclusion seemed to dismiss many of the traditional theories of borderline psychopathology such as Gunderson’s interpersonal hypersensitivity and how attachment disruptions will trigger regressions.
4. In the conclusion, the authors argued that borderline pathology should be retained because of the “extensive treatment” literature but this argument was not put forward in the body of the paper. The authors should have acknowledged the extensive evidence that psychotherapies have been proven effective for the borderline personality disorder. This evidence remains one of the few areas in psychiatry where we have proven interventions targeting borderline pathology that can reduce the risk of future suicide behavior. This evidence should be given as part of the argument for retaining the borderline concept.
Author Response
Dear Editor,
We are grateful for the constructive comments. Below we provide point-by-point responses, including the exact text of proposed revisions.
Comment 1: In the section on Level of Personality Functioning, the authors referred to a “regional tradition” but did not make clear what was meant by this phrase.
Response 1: We thank the reviewer for this observation. We replaced the phrase “regional tradition” with explicit attribution to the co-author’s contribution. This revision eliminates the vague “regional tradition” framing and instead provides transparent disclosure of authorship, specifies the empirical basis of the model, and traces the intellectual lineage. The revised passage is now:
“One of the authors of this review (D.L.T.), a member of the WHO Working Group for ICD-11 Personality Disorders Classification, had previously developed, together with Divac-Jovanović and Svrakic, a dimensional model proposing that one core deficit in personality, broadly resembling Kernberg’s borderline personality organization, represents a common dimension extending across PD categories, whereas discrete PDs are categorical maladaptive behavioral types (Divac-Jovanović M, Svrakic D, Lečić-Toševski D. Personality disorders: Model for conceptual approach and classification: Part I. Am J Psychother 1993; 47: 558–571; Lečić-Toševski D. Description of specific personality disorders. In: New Oxford Textbook of Psychiatry. Oxford University Press, 2000: 927–953). Their data suggested that discrete PDs share the borderline dimension, i.e., that borderline phenomena and features characterize the vast majority of subjects with PDs (Divac-Jovanović et al., 1993). This approach was further elaborated in the proposal that PDs are disorders of adaptation rather than personality per se, since extreme personality traits are not ipso facto dysfunctional (Bach B, Kramer U, Doering S, et al. The ICD-11 classification of personality disorders: A European perspective on challenges and opportunities. Borderline Personal Disord Emot Dysregul 2022; 9: 12). These foundational contributions, spanning three decades of clinical and empirical work (Lečić-Toševski D. Psihijatrija Danas 2004; 36: 243–260; Divac-Jovanović M et al. Psihijatrija Danas 1995; 27: 9–26; Svrakic D, Divac-Jovanović M. Am J Psychother 1994; 48: 562–580; Lečić-Toševski D, Divac-Jovanović M. Psychiatriki 1995; 6: 154–160; Lečić-Toševski D, Divac-Jovanović M. Eur Psychiatry 1996; 11: 244–248), anticipated key features of the dimensional models now adopted in both DSM-5 AMPD and ICD-11.”
Comment 2: On page 5, the authors introduced the “TAT” but did not define this acronym.
Response 2: We apologize for the oversight. TAT refers to the Thematic Apperception Test. We have revised the passage to read: “…through projective tests such as the Rorschach Inkblot Test and the Thematic Apperception Test (TAT)…”
Comment 3: On page 6, the authors indicated that “regression proneness” is an important feature of borderline pathology but suggested that regression only occurs “under the pressure of affective disorder”. This conclusion seemed to dismiss many of the traditional theories of borderline psychopathology such as Gunderson’s interpersonal hypersensitivity and how attachment disruptions will trigger regressions.
Response 3: We recognize that the original formulation inappropriately narrowed the concept of regression proneness. In the revised manuscript, we have broadened the discussion of regression triggers:
“Interpersonal hypersensitivity, depression and low stress tolerance predispose persons to regression to borderline functioning, i.e. temporary borderline decompensation. It can be short-lived and pass after support or adequate treatment. Regression proneness is a stable structural characteristic that can be activated by multiple triggers. These include interpersonal disruptions, particularly perceived or actual abandonment and attachment threats, consistent with Gunderson’s model of interpersonal hypersensitivity as a core feature of borderline pathology (Gunderson JG, Lyons-Ruth K. BPD’s interpersonal hypersensitivity phenotype: A gene-environment-developmental model. J Pers Disord 2008; 22(1): 22–41; Gunderson JG, Herpertz SC, Skodol AE, Torgersen S, Zanarini MC. Borderline personality disorder. Nat Rev Dis Primers 2018; 4: 18029), as well as unstructured situations that activate primary-process thinking (as demonstrated by projective testing), therapeutic relationship ruptures, and affective disorder episodes. The concept of pseudo-borderline syndrome illustrates one specific form of regression in which individuals whose baseline functioning is neurotic transiently exhibit borderline features during an affective episode, with these features remitting once the affective disorder is treated (Lečić-Toševski D, Divac-Jovanović M. Borderline personality disorder and depression. Psychiatriki 1995; 6: 154–160; Lečić-Toševski D, Divac-Jovanović M. Effects of dysthymia on personality assessment. Eur Psychiatry 1996; 11: 244–248). This scenario should not be taken to imply that affective disorder is the sole or primary trigger of regression; rather, it demonstrates that the same surface symptoms may arise from fundamentally different structural substrates.”
Comment 4: In the conclusion, the authors argued that borderline pathology should be retained because of the “extensive treatment” literature but this argument was not put forward in the body of the paper. The authors should have acknowledged the extensive evidence that psychotherapies have been proven effective for the borderline personality disorder. This evidence remains one of the few areas in psychiatry where we have proven interventions targeting borderline pathology that can reduce the risk of future suicide behavior. This evidence should be given as part of the argument for retaining the borderline concept.
Response 4: We thank the reviewer for this important point. We have now included a dedicated passage in the body of the paper addressing the treatment evidence as an argument for retaining the borderline construct:
“Perhaps the most compelling practical argument for retaining the borderline construct lies in the treatment evidence. Borderline personality disorder is one of the few areas in psychiatry where disorder-specific psychotherapies have demonstrated efficacy in randomized controlled trials. Dialectical Behavior Therapy (Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48(12): 1060–1064), Mentalization-Based Treatment (Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009; 166(12): 1355–1364), Transference-Focused Psychotherapy (Doering S, Hörz S, Rentrop M, et al. Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. Br J Psychiatry 2010; 196(5): 389–395), and Schema Therapy (Giesen-Bloo J, van Dyck R, Spinhoven P, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 2006; 63(6): 649–658) have all shown significant reductions in self-harm, suicidal behavior, and core borderline symptoms. These treatments were developed specifically for borderline pathology; thus, abandoning the construct would risk severing the link between this evidence base and the clinical populations it was designed to serve. It may be argued that the therapeutic mechanisms of these treatments are transdiagnostic, applicable to eating disorders, self-harm, and other conditions beyond BPD. However, if borderline pathology indexes the general factor of personality dysfunction, as the present review argues, then the transdiagnostic reach of these interventions is precisely what would be expected: treatments targeting core personality dysfunction will inevitably benefit conditions that share that common substrate. The fact that they work across domains does not make the borderline construct redundant; it confirms its role as a central organizing principle. Of particular relevance, Kernberg’s model of expressive psychotherapy, now primarily known as Transference-Focused Psychotherapy, directly addresses the chaotic internal world of split self and object representations through here-and-now transference interpretation, while Kernberg also recommends supportive psychotherapy, applicable by trained psychotherapists, for patients with more severe borderline pathology characterized by fragile self-esteem, rudimentary superego integration, and preambivalent object relations (Kernberg OF, Caligor E. A psychoanalytic theory of personality disorders. In: Major Theories of Personality Disorder, 2nd ed. Guilford Press, 2005: 114–156). Several of these interventions, particularly MBT and TFP, directly target impairments in self and interpersonal functioning (i.e., the Level of Personality Functioning), further supporting the convergence between the borderline construct and the severity dimension of personality dysfunction (Leichsenring F, Fonagy P, Heim N, Kernberg OF, et al. Borderline personality disorder: A comprehensive review. World Psychiatry 2024; 23: 4–25).”
Reviewer 2 Report
Comments and Suggestions for AuthorsDear Authors,
The article entitled “The Fate of Borderline Personality Disorder in Dimensional Classification Systems 2: A Narrative Analysis” addresses an important and current topic regarding the status of borderline personality disorder in dimensional classification systems of personality disorders.
The paper is well-documented and integrates historical, psychodynamic, and contemporary dimensional models (DSM-5 AMPD and ICD-11). The central argument, according to which borderline personality disorder is an indicator of the severity of personality dysfunction rather than a distinct disorder, is coherent and well-supported.
Here are some suggestions for completing the manuscript:
There is no methodological paragraph indicating how the literature was identified, selected, and prioritized. The manuscript should specify how landmark publications and contemporary contributions were selected and whether the emphasis was historical, conceptual or empirical.
1. The chapter “Introduction and nosological history” is well written, providing a useful historical context for the evolution of the borderline concept. Since the objective of the analysis is not formulated clearly enough, I propose to reformulate the purpose of the study in a separate paragraph.
2. In the chapter “Validity and clinical utility of the borderline construct”, Tyrer and Mulder’s positions are critically discussed, and the main arguments for eliminating the diagnosis of borderline disorder are clearly presented. I would like to clarify the differences between fluctuating symptoms and structural vulnerability.
3. In the chapter “Level of personality functioning” I would like to define more clearly the key concepts (e.g. pseudo-borderline syndrome, predisposition to regression).
4. In the chapter “Discussions” an extensive theoretical analysis is presented. For better clarity of the analysis carried out, I propose to organize the discussion into thematic subsections.
5. The chapter “Conclusions” clearly summarizes the main idea of the article. I propose to add a short section on the limitations of the study and include some directions for future research.
The manuscript contains 58 references relevant to the analyzed topic.
Good luck!
Author Response
We thank the reviewer for the thorough and constructive evaluation. Below we provide point-by-point responses with the exact text of proposed revisions.
Comment1: There is no methodological paragraph indicating how the literature was identified, selected, and prioritized. The manuscript should specify how landmark publications and contemporary contributions were selected and whether the emphasis was historical, conceptual, or empirical.
Response: We agree that the review would benefit from a brief description of the literature selection approach. We will add a short paragraph at the end of Section 1 (Introduction):
“Scope and approach. This narrative review draws on literature identified through searches of PubMed, PsycINFO, and Google Scholar, using terms including ‘borderline pathology,’ ‘borderline personality organization,’ ‘borderline personality disorder,’ ‘borderline pattern descriptor,’ ‘level of personality functioning,’ ‘ICD-11 classification,’ ‘severity,’ and ‘general factor of personality disorder.’ The time frame spans from foundational theoretical contributions (1938 onward) to contemporary publications (through early 2025), with emphasis on the last 15 years. As a narrative review, the literature selection was guided by conceptual relevance and the authors’ expertise rather than by systematic inclusion and exclusion criteria. Priority was given to foundational theoretical works on borderline personality organization, the borderline level of functioning, and dimensional models; WHO Working Group for ICD-11 Personality Disorders Classification publications; major longitudinal studies of BPD course and outcome; and recent empirical contributions to the dimensional classification debate. The review integrates historical, conceptual, and empirical perspectives, with the primary emphasis being conceptual, examining how the borderline construct has been understood across theoretical frameworks and what its place should be in contemporary dimensional systems.”
Comment 1: The chapter “Introduction and nosological history” is well written, providing a useful historical context for the evolution of the borderline concept. Since the objective of the analysis is not formulated clearly enough, I propose to reformulate the purpose of the study in a separate paragraph.
Response 1: We thank the reviewer for this suggestion. We will add the following paragraph at the end of Section 1:
“The present review has three aims: first, to trace the nosological evolution of the borderline construct from early psychoanalytic descriptions through its operationalization in DSM-III and subsequent dimensional reforms in DSM-5 AMPD and ICD-11; second, to critically examine the principal arguments advanced for excluding borderline pathology from diagnostic classification systems and the evidence that complicates a straightforward conclusion of redundancy; and third, to propose a synthesis in which borderline pathology is reconceptualized as a clinically meaningful dimension of structural vulnerability and severity—a dimension that indexes the general factor of personality dysfunction—integrating the concept of the borderline level of personality functioning with the Level of Personality Functioning (Criterion A) of the DSM-5 AMPD and the ICD-11 severity continuum.”
Comment 2: In the chapter “Validity and clinical utility of the borderline construct,” Tyrer and Mulder’s positions are critically discussed, and the main arguments for eliminating the diagnosis of borderline disorder are clearly presented. I would like to clarify the differences between fluctuating symptoms and structural vulnerability.
Response 2: We have expanded subsection 4.1 with longitudinal evidence demonstrating the dissociation between symptomatic remission and persistent structural/functional impairment:
“This dissociation between surface-level symptom change and enduring structural deficit has been empirically documented in major longitudinal studies. In the McLean Study of Adult Development, Zanarini and colleagues classified BPD symptoms into acute manifestations (rapidly remitting, such as self-mutilation and quasi-psychotic episodes) and temperamental features (persistent, such as chronic emptiness and abandonment concerns); while 93% of patients achieved symptomatic remission over 10 years, only 50% attained concurrent functional recovery (Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. Prediction of the 10-year course of borderline personality disorder. Am J Psychiatry 2006; 163(5): 827–832; Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and Axis II comparison subjects: a 16-year prospective follow-up study. Am J Psychiatry 2012; 169(5): 476–483). Data from the Collaborative Longitudinal Personality Disorders Study yielded comparable findings: approximately 85% symptomatic remission but only 20% functional remission at 10 years (Gunderson JG, Stout RL, McGlashan TH, et al. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Arch Gen Psychiatry 2011; 68(8): 827–837). Skodol and colleagues further demonstrated that functional impairment in BPD remained stable over two years despite some diagnostic improvement (Skodol AE, Pagano ME, Bender DS, et al. Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med 2005; 35(3): 443–451). McGlashan et al. proposed a hybrid model in which personality disorders consist of stable traits and intermittently expressed symptomatic behaviors, a formulation that captures the clinical reality of enduring vulnerability with episodic symptomatic expression (McGlashan TH, Grilo CM, Sanislow CA, et al. Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of Axis II disorders. Am J Psychiatry 2005; 162(5): 883–889). These convergent findings across independent longitudinal cohorts support the distinction drawn in the present review between fluctuating symptomatic manifestations and the stable structural vulnerability that constitutes the borderline level of personality functioning.”
Comment 3: In the chapter “Level of personality functioning,” I would like to define more clearly the key concepts (e.g., pseudo-borderline syndrome, predisposition to regression).
Response 3: We will expand the definitions of both concepts in Section 3.
Regarding the pseudo-borderline syndrome:
“Within this framework, the concept of pseudo-borderline syndrome was introduced to describe a clinical presentation in which individuals whose baseline personality functioning is neurotic—characterized by integrated identity, mature defense organization, and intact reality testing—transiently exhibit borderline features (affective instability, diffuse identity, impulsive behavior, transient paranoid ideation) during the course of an affective disorder, most commonly major depression or dysthymia. Crucially, these borderline symptoms remit with successful treatment of the affective episode, revealing that the borderline presentation was state-dependent rather than reflecting a structural personality deficit (Lečić-Toševski D, Divac-Jovanović M. Borderline personality disorder and depression. Psychiatriki 1995; 6: 154–160; Lečić-Toševski D, Divac-Jovanović M. Effects of dysthymia on personality assessment. Eur Psychiatry 1996; 11: 244–248). The concept was developed on the basis of clinical observations that dysthymic disorder significantly distorts personality assessment, producing apparent borderline features that resolve when the affective condition is treated. The clinical significance of this distinction extends beyond nosology: when affective and personality pathology coexist, as they frequently do, determining which is primary may be impossible on cross-sectional assessment alone, yet simultaneous improvement at both levels is needed if any progress is to be made (Lečić-Toševski D, Divac-Jovanović M, Jašović-Gašić M, et al. Personality and psychopathology. In: Bentall RP, Morrison AP, eds. Current Topics in Personality and Psychopathology. World Scientific, 2010). The pseudo-borderline concept directly illustrates why the level of personality functioning must be understood as a dynamic dimension: the same surface symptoms may arise from fundamentally different structural substrates, with correspondingly different treatment implications and prognoses.”
Regarding regression proneness:
“Regression proneness is defined here as a stable structural characteristic of borderline personality organization, reflecting the individual’s enduring vulnerability to transient shifts toward more primitive modes of functioning—primary-process thinking, activation of splitting and projective identification, disturbances in reality testing—under conditions of internal or external stress. Following Kernberg (Kernberg OF. Borderline Conditions and Pathological Narcissism. New York: Jason Aronson, 1975; Kernberg OF. Severe Personality Disorders: Psychotherapeutic Strategies. New Haven: Yale University Press, 1984), what remains stable is the structural capacity for regression; what varies is only the occasion and intensity of its activation. Triggers for regression include interpersonal disruptions (perceived or actual abandonment, attachment threats), unstructured situations, therapeutic relationship ruptures, and affective episodes. This dynamic characteristic is one of the most clinically consequential features of borderline pathology—and a major source of treatment difficulty—yet it is omitted from the nine DSM-5 BPD criteria and from the ICD-11 borderline pattern specifier, and is even less likely to be captured by trait domain descriptors alone. Regression proneness has been empirically demonstrated through projective assessment: Rorschach Inkblot Test and Thematic Apperception Test (TAT) studies have consistently shown that BPD patients exhibit primary-process thinking with activation of primitive defenses and disturbed object representations when assessed with unstructured stimuli (Leichsenring F, Fonagy P, Heim N, Kernberg OF, et al. Borderline personality disorder: A comprehensive review. World Psychiatry 2024; 23: 4–25; Lerner PM. Rorschach assessment of primitive defenses in borderline personality structure. J Pers Assess 1990; 54(1–2): 30–46; Acklin MW. Psychodiagnosis of personality structure: psychotic personality organization. J Pers Assess 1993; 61(2): 329–341).”
Comment 4: In the chapter “Discussions,” an extensive theoretical analysis is presented. For better clarity of the analysis carried out, I propose to organize the discussion into thematic subsections.
Response 4: We will reorganize the Discussion into four subsections. No content will be removed; existing paragraphs will be redistributed under the following headings:
4.1. Fluctuating symptoms or enduring structural vulnerability?, paragraphs on the first argument + new longitudinal evidence (see Response 2 above)
4.2. The borderline factor, paragraphs on factor-analytic findings, bifactor modeling, HiTOP, and the Circumplex of Personality Metatraits
4.3. Clinical utility, paragraphs on diagnostic redundancy + new paragraph on treatment evidence (addressing Reviewer 1, Comment 4)
4.4. Toward a synthesis: borderline pathology as a severity dimension, integrating paragraph
Comment 5: The chapter “Conclusions” clearly summarizes the main idea of the article. I propose to add a short section on the limitations of the study and include some directions for future research.
Response 5: We will add the following subsection:
Limitations and future directions
“As a narrative review, literature selection was guided by conceptual relevance and the authors’ theoretical perspective rather than systematic criteria; the analysis may not capture all relevant studies and may reflect the interpretive emphasis inherent to psychodynamic and dimensional approaches. Research priorities include: longitudinal testing of whether borderline features prospectively predict the trajectory of overall personality dysfunction; investigation of whether borderline pathology retains incremental predictive validity for treatment response, self-harm, and functional recovery beyond what severity ratings alone can capture; and examination of the relationship between the general factor of personality disorder and borderline pathology across diverse samples, including adolescents, where early identification may alter developmental course. The most pressing question is translational: dimensional systems now require clinicians to rate severity levels and trait domains, yet real-world data on how these ratings perform in routine practice remain scarce. It is still unknown whether severity and domain assessments can be reliably implemented across diverse clinical settings, including those with limited resources. In this context, the borderline pattern, with its long-established clinical recognizability, may serve as a practical anchor for severity assessment, offering clinicians a familiar configuration that specifies what moderate-to-severe personality dysfunction looks like in practice.”
