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CEFS 546 Borderline Personality Disorder Research Paper Outline
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Borderline Personality Disorder Research PaperOutline
I. Historical Development of the Concept
II. Core Symptoms and Character Styles
III. Demographic and Data-Based Studies
IV. Etiology and Relationship to Other Disorders
A. Psychoanalytic Hypotheses
B. BPD as an Affective Spectrum Disorder
C. BPD as Posttraumatic Stress Disorder Secondary to Childhood Sexual and Physical Abuse
D. BPD as an Impulse Spectrum Disorder
V. Course of Borderline Personality Disorder
VI. Treatment of BPD
I. Historical Development of the Concept
More than one decade after the development and publication of DSM-III, borderline personality
disorder (BPD) remains the most controversial category in the nomenclature. Disagreement
persists regarding the term itself, the particular diagnostic criteria established 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 intensity 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 validity: whether the BPD construct describes a meaningful unitary syndrome that
corresponds to an actually existing state of affairs. While this latter question can certainly be
asked of any of the personality (Axis II) disorders, 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 observation 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 transient psychotic symptoms and they did
not meet classical definitions of schizophrenia. It is not that they did not necessarily improve;
many obsessional patients, for example, did not improve with psychotherapy. Rather, it is that
these patients worsened in psychotherapy with a fairly specific pattern of acting out that
,showed up most dramatically in the development of severe transference problems. The
difficulty confronting the predominantly psychoanalytic theoreticians 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
encompassing 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 category 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
pseudoneurotic 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 schizophrenia construct was that the patients did not go
on to develop the more classical symptoms of hallucinations 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 character 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 psychiatrists fit much better with manic-depressive
and personality disorder symptoms and outcome. This diagnostic realignment tightened the
diagnostic criteria for schizophrenia, thereby further emphasizing the differences between
borderline conditions and schizophrenia.
In 1968, Grinker and colleagues published the results of their study of 58 hospitalized patients
who fell into a broadly defined notion of borderline syndrome. 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 psychometric instruments and statistical analyses, moved the borderline
concept away from the realm of schizophrenic 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 carried out by Gunderson and Singer in 1975,
the primary diagnostic concern was still to demonstrate that borderlines were different than
,schizophrenics. At the same time that empirical studies were focusing on narrowing the
construct of borderline, Kernberg developed a broader notion of borderline, based upon a
fusion of ego psychology and object relations theory, to designate a form of personality
organization that was characterized by the use of primitive ego defenses (denial, 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)personality
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 competing and overlapping concepts of
borderline, and the final result represented some degree of compromise between the various
groups. Since ideological and economic considerations, in addition to empirical studies and
clinical lore, influenced the final product, it is important to define these considerations in some
detail. The four overlapping concepts of borderline were as follows: (1) A residual model based
upon the schizophrenic spectrum concept, using the term borderline to designate those
persons, usually relatives of schizophrenics, 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 suicide. (3) An empirically derived model based primarily 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 instability with primarily negative affects; disturbed but intense interpersonal
relationships; and an unstable sense of self. (4) A psychoanalytic concept based primarily on the
work of Kernberg, but encompassing theoretical formulations by Mahler relating to difficulties
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 personality disorders
within Axis II, not based upon empirical 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 disturbances that had long been noticed were placed in the schizotypal
personality disorder, the milder dramatic and attention-seeking traits were placed into the
histrionic personality disorder, self-centeredness and entitlement became the core of the
narcissistic personality disorder, and the affective symptoms of mood instability and negative
affectivity (depression, anger, anxiety), along with impulsivity, were given prominence 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 relationships, 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 relationships characterized by
alternating between extremes of overidealization and devaluation.
2. Impulsiveness in at least two areas that are potentially 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, usually 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, constant anger, physical fights.
5. Recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior.
6. Marked and persistent identity disturbance manifested by uncertainty about at least
two of the following: self-image, sexual orientation, long-term goals or career choice,
type of friends desired, preferred 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 completed by late 1993. Although the BPD construct
did not undergo any major alterations, several changes were instituted which served to correct
the overemphasis 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 disturbances 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 Criterion 6 was reworded and the construct “boredom” was dropped
from Criterion 7.
II. Core Symptoms and Character Style
The clinical description of a psychiatric disorder does not correspond exactly to that disorder’s
diagnostic criteria in DSM-III. The main reason for this is that a clinical description needs to be a
full and rich portrayal of the condition under question, whereas the requirements for diagnostic
criteria are vastly different. Diagnostic criteria must aim for those characteristics of an illness
that capture a few of its core symptoms while avoiding overlap with neighboring conditions. For
example, as indicated above, while boredom may very well be a characteristic mental state in
BPD, it was also found in histrionic and narcissistic personality disorders and therefore was of
little specific diagnostic value. It did not help discriminate between BPD and other Cluster B
personality disorders. In addition, diagnostic criteria must have acceptable validity and
reliability. The issue of validity of psychiatric disorders, especially of personality disorders, is a
troublesome one, since there are not external validators. The construction of DSM-III had paid
major attention, some would say excessively so, to reliability issues. For example, certain
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