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haul,” focusing on her dependency and stabilization of her identity and relationships, rather than on an endless succession of acute emergencies.
    Carrie, at forty-six, has had to learn that an entire set of previous behaviors are no longer acceptable. “I don’t have the option of cutting myself, or overdosing, or being hospitalized anymore. I vowed I would live in and deal with the real world, but I’ll tell you, it’s a frightening place. I’m not sure yet whether I can do it or whether I want to do it.”

Borderline: A Personality Disorder
    Carrie’s journey through this maze of psychiatric and medical symptoms and diagnoses exemplifies the confusion and desperation experienced by individuals afflicted with mental illness and by those who minister to them. Though the specifics of Carrie’s case might be considered extreme by some, millions of women—and men—suffer similar problems with relationships, intimacy, depression, and drug abuse. Perhaps if she had been diagnosed earlier and more accurately, she would have been spared some of the pain and loneliness.
    Though borderline personalities suffer a tangle of painful symptoms that severely disrupt their lives, only recently have psychiatrists begun to understand the disorder and treat it effectively. What is a “personality disorder”? What exactly does borderline border? How is borderline personality similar to and different from other disorders? How does the borderline syndrome fit into the overall schema of psychiatric medicine? These are difficult questions even for the professional, particularly in light of the elusive, paradoxical nature of the illness and its curious evolution in psychiatry.
    One widely accepted model suggests that individual personality is actually a combination of temperament (inherited personal characteristics, such as impatience, vulnerability to addiction, etc.) and character (developmental values emerging from environment and life experiences)—in other words a “nature-nurture” mix. Temperament characteristics may be correlated with genetic and biological markers, develop early in life, and are perceived as instincts or habits. Character emerges more slowly into adulthood, shaped by encounters in the world. Through the lens of this model, BPD may be viewed as the collage resulting from the collision of genes and environment. 1 , 2
    BPD is one of ten personality disorders noted in DSM-IV-TR: in DSM terminology personality disorders are categorized on Axis II. (See Appendix A for a more detailed discussion of categorization in DSM-IV-TR.) These disorders are distinguished by a cluster of developing traits that become prominent in an individual’s behavior. These traits are relatively inflexible and result in maladaptive patterns of perceiving, behaving, and relating to others.
    In contrast, state disorders (Axis I in DSM-IV-TR) are usually not as enduring as trait disorders. State disorders, such as depression, schizophrenia, anorexia nervosa, chemical dependency, are more often time- or episode-limited. Symptoms may emerge suddenly and then be resolved, as the patient returns to “normal.” Many times these illnesses are directly correlated with imbalances in the body’s biochemistry and can often be treated with medications, which virtually eliminate the symptoms.
    Symptoms of a personality disorder, on the other hand, tend to be more durable traits and change only gradually; medications are, in general, less effective. Psychotherapy is primarily indicated, though other treatments, including medication, may alleviate many symptoms, especially severe agitation or depression (see chapter 9). In most cases, borderline and other personality disorders are a secondary diagnosis, describing the underlying characterological functioning of a patient who exhibits more acute and prominent symptoms of a state disorder.
Comparisons to Other Disorders
    Because the borderline