Quiet Borderline: A Closer Look at Subtypes

Regarding presentations of borderline personality disorder and structures, Theodore Millon states:
“…borderline may be analogized to the dumplings on Chinese menus. They look alike on the outside, but can be filled with any number of inner ingredients, pork, chicken, various vegetables, and so on. So, too, the borderline classification may be composed internally with a wide range of diverse, coexisting other Axis I and II disorders,” (Millon, 2011, p. 891). Gunderson (2010) did the math and reported that because at least 5 out of 9 criteria are required to be diagnosed with borderline personality disorder, there are 256 possible combinations of the criteria at a diagnostic level. No wonder we have an interest in what different borderline personality disorder subtypes there are! It’s extremely diverse! Yet, the DSM-5-TR does not list any subtypes for borderline personality disorder…

The Origin of Quiet Borderline

The most common subtype that’s all over the internet right now is Quiet Borderline or Quiet BPD, but where did that term come from? You can look here for a brief description of the history of borderline personality disorder. It actually wasn’t until 1991 (later expanded on in 1994) when Sherwood and Cohen coined the term Quiet Borderline, comparing it to Deutsch’s (1942) proposal of the “As-If patient.” Johnston (2010, p. 242) provides us with an example where nurses in an inpatient setting were distracted by the Noisy Borderlines (i.e. self-harm, outward dramatics) and often forgot the Quiet Borderline who stayed in the bathroom away from the “madness.” But since then, the research about Quiet Borderline has died off in the past 20 years.

The Current Research on Borderline Personality Disorder Subtypes

So I dug into the current research on borderline personality disorder subtypes. If you want to do the same, I suggest starting with Wolf (2023) and picking out some hallmark articles. Basically, there’s a ton of different ways researchers have done their magical analyses and come up with subtypes. Subtypes have been explored based on things like severity, symptoms, self-harm, co-occurring conditions, features of other personality disorders, internal vs. external factors, etc. The conclusion is: we don’t know. There is not currently any agreement or consensus on borderline personality disorder subtypes. But we have learned some things! Yay research!

My Understanding of Borderline Personality Disorder Subtypes

Based on my look at the research on borderline personality disorder subtypes, I think most can be organized in three categories: Internalized, Externalized, and Mixed-Ambivalent (which also mirrors some previous research outlined in the supplemental materials for Wolf, 2023, as well as their own results). However, there is bound to be overlap and exceptions. It is my opinion that Borderline isn’t really meant to be contained into categories.

Internalized Borderline Personality Disorder Subtype

The internalized subtype seems to capture the borderline personality disorder presentations that trend toward withdrawing and pulling away from others because of rejection sensitivity. They are schizoid-y (maybe more Cluster A, but not paranoid), hiding in their protective shell like a turtle, and being more passive, conforming, peaceful, and outwardly stable. They can be more “heady” and dissociative, which can make them seem “higher functioning;” thus, their borderline personality disorder symptoms are more likely to come out in their closest relationships. They can easily fall apart and step out of reality because they are extremely sensitive and filled with emptiness and deep emotional pain. They are more depressive, and their impulsivity is directed toward the self, which can result in more self-harm, sabotage behaviors, and self-destruction.

Externalized Borderline Personality Disorder Subtype

In contrast to the internalized subtype, the externalized subtype seems to capture the borderline personality disorder presentations that trend toward intrusiveness and pushing boundaries in their desire to connect to others. Like the lanternfly, they intrude and can be harmful, but maintain their beauty. They tend to have more Cluster B traits like narcissism (self-focused, egotistical), histrionic (showy, flashy, shallow but dramatic emotions), and antisocial (nonconforming, going against social rules). They also are not paranoid, as they are not anxious. Instead, they tend to act against any anxiety they have by “running into the fire,” being “brave,” and “peacocking.” Their anger is overt, and there can be aggressiveness (especially in males). Their impulsivity is also external, as they might abuse substances, drive recklessly, and engage in risky intimate behaviors. The externalized subtype seems to be more in line with the DSM-5-TR criteria.

Mixed-Ambivalent Borderline Personality Disorder Subtype

The mixed-ambivalent subtype seems to be more of a classic “push-pull” borderline dynamic, like porcupines on a cold night. Snuggling close is prickly and hurtful, but distance is so cold. They have a more “core” borderline presentation with a major conflict between keeping attachments vs. being independent, which can result in an (un)conscious dislike of their attachments and passive-aggressiveness. There are more Cluster C traits, such as going back and forth between avoidance and dependence. There can also be a really strong compulsive “shell,” meaning that this subtype can work SO very hard to keep themselves together and people-please, but there is still deep internal pain and anger that they have to act that way. This results in resentment and repressed anger, which can leak out when their shell starts to crack. Sometimes there might even be a negativistic flavor of this subtype, in which their bitterness toward others for having to be dependent, as well as their own anger and dislike of themself, is turned onto others.

Quiet Borderline’s Subtype

Okay, so I organized things into three categories: Internalized, Externalized, and Mixed-Ambivalent. But where does our current cultural understanding of Quiet Borderline/Quiet BPD fall? Using the above categories, I think Quiet Borderline falls between the internalizing and mixed-ambivalent subtypes. The internalizing subtype of Quiet Borderline makes sense because it’s obviously quieter with more internal chaos and less overt dramatics. But I also think that Quiet Borderline can be a mixed-ambivalent subtype where they are higher functioning with a compulsive shell, allowing them to present as “quieter” (until it cracks).

So…I believe the term “Quiet Borderline” not only lost its original meaning from 1991, but is being thrown around incorrectly to describe a vast array of borderline personality presentations that aren’t as externalizing and dramatic as the DSM-5-TR criteria portray. Honestly, I think this leads us back to the argument that “borderline” is an organizational level and does not do well as a diagnostic category (see blog/podcast). Regardless, we can still continue to try to understand borderline personality disorder in all the ways!

References

• Cohen, C. P., & Sherwood, V. R. (1991). Becoming a constant object in psychotherapy with the borderline patient. Jason Aronson.
• Deutsch, H. (1942). Some forms of emotional disturbance and their relationship to schizophrenia. The Psychoanalytic Quarterly, 11(3), 301-321. https://doi.org/10.1002/j.2167-4086.2007.tb00257.x
• Gunderson, M. D. (2010). Revising the borderline diagnosis for DSM-V: An alternative proposal. Journal of Personality Disorders, 24, 694–708.
• Johnston, J. (2010). Being disturbed: Integration and disintegration in the patient and professional relationship. Psychoanalytic Psychotherapy, 24(3), 231-251. https://doi.org/10.1080/02668734.2010.502306
• Millon, T. (2011). Disorders of personality: Introducing a DSM / ICD spectrum from normal to abnormal (3rd edition). John Wiley & Sons, Inc.
• Sherwood, V. R., & Cohen, C. P. (1994). Psychotherapy of the quiet borderline patient: The as-if personality revisited. Jason Aronson.
• Wolf, K., Scharoba, J., Noack, R., Keller, A., & Weidner, K. (2023). Subtypes of borderline personality disorder in a day-clinic setting—Clinical and therapeutic differences. Personality Disorders: Theory, Research, and Treatment, 14(5), 555–566. https://doi.org/10.1037/per0000624