Drs. Zanarini and Frankenburg Reply

To the Editor: We appreciate the comments of Dr. Salzman, who brings up the important issue of whether sexual abuse is associated with the etiology of borderline personality disorder per se or only with that of severe inpatient cases of borderline personality disorder. Previous research has found that the rates of childhood sexual abuse are about the same for criteria-defined borderline outpatients and inpatients (1–9). Dr. Salzman and her colleagues, however, found a substantially lower rate of abuse in a group of symptomatic volunteers (10).

Clinical experience suggests that the boundary between outpatients and inpatients with borderline personality disorder is quite permeable, with today’s outpatient being tomorrow’s inpatient and vice versa. In this regard, it is important to note that studies have consistently found that a substantial percentage of outpatients with borderline personality disorder have a history of prior hospitalization (11, 12).

Thus, Dr. Salzman is highlighting the existence of a third group of patients—mild outpatient cases of borderline personality disorder with no history of psychiatric hospitalization. In our clinical experience, patients with the diagnosis of borderline personality disorder who have never been hospitalized lack the impulsivity of those patients who have been inpatients, since patients with borderline personality disorder are typically hospitalized for their own protection during periods of intense self-destructiveness. This raises the question of whether “borderline” patients who have never been hospitalized are, in fact, borderline at all or whether they should be considered patients with borderline traits or features. To phrase the question another way: should nonimpulsive patients who manifest the intense dysphoria, suspiciousness and dissociation, and difficult, stormy relationships characteristic of borderline personality disorder be considered borderline? Should someone without a history of deliberate physical self-harm, help-seeking suicidal efforts, or both be thought of as a borderline patient?

Further research is needed to untangle these issues. Until that time, we can only reiterate that even in the most severely impaired of borderline subjects, we have found that childhood sexual abuse is neither necessary nor sufficient for the development of borderline personality disorder.