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There are very few certainties in psychiatry. At least one division of psychiatric states about which many psychiatrists have felt reasonably certain is that between psychotic and non-psychotic conditions. Some disorders, however, puzzle the observer because they seem to straddle the divide, like some forms of hysteria, Multiple Personality Disorder, or non-productive forms of schizophrenia. Borderline personality disorder (BPD) epitomizes the problem and we have chosen it as a test case to elucidate the strengths and weaknesses of different ways of conceptualizing psychosis. BPD continues to be a disputed clinical entity for many psychiatrists and indeed is not recognized in ICD 10. In contrast, in the USA it was first included in DSM III and remains in its revision. Questions have been raised not only about the validity of the disorder as a nosological entity but also about the value of retaining it or dismissing it on purely practical and semantic grounds.
We argue that understanding the reasons for the continuing debate and resistance to the acceptance of BPD requires examination of wider conceptual issues. It is not surprising that a syndrome that seems to vacillate between psychosis and non-psychosis, and state and trait psychiatric disorder, be met with emotional resistance and intellectual objection. Incomplete knowledge may contribute to this unease but BPD is the most investigated personality disorder of recent years (Blashfield and McElroy, 1987). An earlier paper (Tarnopolsky and Berelowitz, 1984) showed that while 65% of Maudsley psychiatrists were familiar with the concept and vocabulary of BPD, many objected strongly to it. The authors of this paper propose that part of the difficulty with accepting BPD results from the challenge that it presents to conceptualizing psychosis; we will