Mental health articles

BORDERLINE PERSONALITY DISORDER is a term that identifies a heterogenous group of patients with serious character pathology and behavioral dis- turbances. The main features of this disorder are behavior that is impulsive, dramatic, and often self- destructive; moods that are labile and reactive to life circumstances; interpersonal relationships that are stormy; and a sense of self-identity that is fragile and contradictory.

More than one decade after the development and publication of DSM-III, borderline personality dis- order (BPD) remains the most controversial category in the nomenclature. Disagreement persists regarding the term itself, the particular diagnostic criteria estab- lished for BPD by DSM-III and DSM-IV, the scope of applicability, and the extent of overlap with Axis I and other Axis II disorders. Ultimately, this degree and in- tensity of dispute reflect both the range of difficulties in identifying and working with those persons designated as borderline, as well as the more basic question of va- lidity: whether the BPD construct describes a meaning- ful unitary syndrome that corresponds to an actually existing state of affairs. While this latter question can certainly be asked of any ofthe personality (Axis II) dis- orders, something about the borderline concept seems to have engendered the strongest controversy. At least one major reason for the ongoing disputes is the fact that the very concept of borderline was born out of attempts to explain the clinical observa- tion that certain patients seemed to do very poorly in psychodynamic psychotherapy. Thus, from the very first, this category was used to describe a disparate group of patients who had two things in common: they responded to psychotherapy by developing tran- sient psychotic symptoms and they did not meet clas- sical definitions of schizophrenia. It is not that they did not necessarily improve; many obsessional pa- tients, for example, did not improve with psycho- therapy. Rather, it is that these patients worsened in psychotherapy with a fairly specific pattern of acting out that showed up most dramatically in the develop- ment of severe transference problems.

The difficulty confronting the predominantly psychoanalytic theo- reticians and skilled therapists was how to fathom the nature of these patients who gave promise of being good psychotherapeutic cases, yet deteriorated during the course of a psychotherapy. Thus, the very origins of the borderline concept arose in the context of a clinical puzzle. The solution to the puzzle, keeping in mind that American psychiatry held a much more encompass- ing concept of schizophrenia in the 1940s and 1950s than at present, was to conceptualize these patients who became worse in psychotherapy as having a schizophrenic core underlying the neurotic facade. This notion was given concrete expression in a paper by Hoch and Polatin in 1949 describing the new cate- gory of pseudoneurotic schizophrenia.

The construct fit neatly into a psychoanalytic model that postulated a spectrum of psychopathology based upon increasing primitiveness of defense mechanisms, extending in an unbroken chain from mild neurotics at one end to deteriorated schizophrenics at the other. The pseudo- neurotic patient served as the missing link, bridging neurosis and psychosis, and thus serving as visible proof of the continuity connecting mild and severe psychiatric disorders.

The problem with the pseudoneurotic schizophre- nia construct was that the patients did not go on to develop the more classical symptoms of hallucina- tions and delusions nor the deteriorating course that is the usual outcome of schizophrenia. Nevertheless, the observation that there existed a group of patients who appeared neurotic, but worsened with intensive psychotherapy, was a valid finding that outlived the misleading label attached to it. The focus of what might be wrong with these difficult-to-treat patients shifted away from schizophrenia to consideration of severe character pathology, described as borderline states by Knight in 1953 and as the psychotic char- acter by Frosch in 1964. In addition, the joint U.S.- U.K. diagnostic studies carried out in the mid-to-late 1960s demonstrated convincingly that many patients diagnosed as schizophrenic by American psychia trists fit much better with manic-depressive and per- sonality disorder symptoms and outcome.

This diag- nostic realignment tightened the diagnostic criteria for schizophrenia, thereby further emphasizing the differences between borderline conditions and schizo- phrenia. In 1968, Grinker and colleagues published the re- sults of their study of 58 hospitalized patients who fell into a broadly defined notion of borderline syn- drome. These patients had difficulties in interpersonal relationships, transient losses of reality testing under stress, angry and depressive affects, and deficient self- identities. Cluster analyses of the data, primarily of measurements of ego functions, produced four major clusters. There was a “core” borderline group, two groups defined as bordering upon the psychoses and neuroses, and a fourth group embodying certain “as-if” features, most notably absence of a core self- identity.

Grinker’s study, the first to utilize psycho- metric instruments and statistical analyses, moved the borderline concept away from the realm of schizo- phrenic spectrum disorders and provided the basis for future empirical studies that continued the attempt to define the still vague borderline syndrome. It is instructive that in the next series of studies car- ried out by Gunderson and Singer in 1975, the pri- mary diagnostic concern was still to demonstrate that borderlines were different than schizophrenics.

At the same time that empirical studies were focusing on nar- rowing the construct of borderline, Kernberg devel- oped a broader notion of borderline, based upon a fu- sion of ego psychology and object relations theory, to designate a form of personality organization that was characterized by the use of primitive ego defenses (de- nial, splitting, projective identification), intact reality testing (with transient regressions under stress), and identity diffusion. Kernberg’s construct of borderline personality organization includes the milder as well as the more severe forms of character pathology, and, in essence, encompasses most of the patients presently grouped under the Cluster B (dramatic, unstable)per- sonality disorders: histrionic, narcissistic, borderline, and antisocial. This was the state of affairs while the DSM-IV committee developed inclusion and exclusion criteria for the personality disorders.

There were four compet- ing and overlapping concepts of borderline, and the fi- nal result represented some degree of compromise be tween the various groups. Since ideological and eco- nomic considerations, in addition to empirical studies and clinical lore, influenced the final product, it is im- portant to define these considerations in some detail. The four overlapping concepts of borderline were as follows:

(1) A residual model based upon the schizo- phrenic spectrum concept, using the term borderline to designate those persons, usually relatives of schizo- phrenics, who displayed odd, eccentric thinking and schizoid interpersonal relationships; this group was given the term schizotypal personality disorder.

(2) An affective disorder model, which considered BPD as an affective spectrum illness displaying prominent features of mood instability with a predominance of depression, anger, and preoccupations with sui- cide.

(3) An empirically derived model based pri- marily on the research of Gunderson, with diagnostic symptoms placed into five major groupings: impulse/ action patterns (including self-destructive behaviors); ego-dystonic, transient psychotic episodes; mood in- stability with primarily negative affects; disturbed but intense interpersonal relationships; and an unstable sense of self.

(4) A psychoanalytic concept based pri- marily on the work of Kernberg, but encompassing theoretical formulations by Mahler relating to diffi- culties in the separation/individuation phase of child development. The final configuration of BPD adopted was most influenced by Gunderson’s work, but nevertheless showed the strains inherent in a compromise between points of view that are ideologically very divergent. The results were the creation of several new person- ality disorders within Axis II, not based upon empiri- cal studies, but with each reflecting to some extent components that were once loosely connected to the borderline concept. Essentially, in dividing the broad territory of the borderline syndrome, as this concept evolved during a 40-year span, the cognitive distur- bances that had long been noticed were placed in the schizotypal personality disorder, the milder dramatic and attention-seeking traits were placed into the his- trionic personality disorder, self-centeredness and en- titlement became the core of the narcissistic person- ality disorder, and the affective symptoms of mood instability and negative affectivity (depression, anger, anxiety), along with impulsivity, were given promi- nence in the borderline personality disorder.

Borderline personality disorder was defined by DSM-III-R as a condition marked by a pervasive pattern of instability of mood, interpersonal relation- ships, and self-image, beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following:

1. A pattern of unstable and intense interpersonal re- lationships characterized by alternating between extremes of overidealization and devaluation.

2. Impulsiveness in at least two areas that are poten- tially self-damaging, e.g., spending, sex, substance use, shoplifting, reckless driving, binge eating.

3. Affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usu- ally lasting a few hours and only rarely more than a few days.

4. Inappropriate, intense anger or lack of control of anger, e.g., frequent displays of temper, con- stant anger, physical fights.

5. Recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior.

6. Marked and persistent identity disturbance mani- fested by uncertainty about at least two of the fol- lowing: self-image, sexual orientation, long-term goals or career choice, type of friends desired, pre- ferred values.

7. Chronic feeling of emptiness or boredom.

8. Frantic efforts to avoid real or imagined abandonment. The revision of DSM-III-R into DSM-IV was com- pleted by late 1993. Although the BPD construct did not undergo any major alterations, several changes were instituted which served to correct the overem- phasis in DSM-III on the close relationship between BPD and the affective disorders and the omission of cognitive deficits. Criterion 3 (Criterion 6 in DSM-IV), which outlined the affective symptoms seen in BPD was changed to reflect reactivity of mood; this serves to emphasize the difference between the mood dis- turbances seen in BPD and the relatively situation- independent mood disturbances characteristic of the endogenous affective disorders (major depression and manic-depressive illnesses). Complementing this more accurate delineation of the type of mood disorder seen in BPD was the inclusion of a new criterion to reflect the specific cognitive disturbances of BPD. The DSM- IV calls for a ninth criterion as follows: Transient stress-related paranoid ideation or severe dissociative symptoms. There were a few additional changes to the original eight criteria, but these are relatively minor, either reflecting grammatical alterations in the interest of clarity or the result of low sensitivity/specificity ratings for a few items on further field testing. Thus, the description of the identity disturbance in Crite- rion 6 was reworded and the construct “boredom” was dropped from Criterion 7.

Tags: disorder, lity Disorder, personality, Personality Disorder