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Borderline Personality Disorder Introduction

The construct of a borderline personality has undergone several transformations during the past few decades. These transformations reflect shifts in our understanding and revisions in our treatment of this disorder.

Patients with borderline personality were originally thought to have a type of intrapsychic organization based on primarily psychoanalytic observations. The prospect of being able to understand the internal organization of such patients helped encourage the enormous rise in therapeutic enthusiasm for long-term, intensive, psychoanalytically informed treatments for these patients.

The widespread use of the borderline personality organization construct was modified by empirical evidence that it could be defined as a syndrome with reliably identifiable and discriminating criteria (

see Table 83-1 for the DSM-IV criteria). After the adoption of borderline personality disorder (BPD) in DSM-III (American Psychiatric Association 1980), the disorder became the subject of empirical study. Other research directed at the psychopathology of borderline patients has begun to inform clinicians about the possible etiologies, prevalent comorbidity, and range of outcomes of the disorder. Such studies showed that although patients can recover from BPD, recovery does not depend on long-term intensive psychoanalytic therapy. Empirical investigations repeatedly found that borderline patients have significant deficits in their ability to tolerate affects, impulses, and aloneness. From these observations, as well as more general changes in mental health services, the treatment approach of the earlier era, in which long-term, intensive psychoanalytic therapies were considered necessary, has been greatly modified.

Studies have now been conducted in which the merits of psychoanalytic therapies, pharmacotherapies, and a range of sociotherapies (e.g., partial hospital, group, family, and cognitive-behavioral therapies) have been demonstrated. Clinicians now start with a recognition that although long-term treatment may be needed, many time-limited therapies can be helpful and that focused interventions, which are directed at the major deficits characteristic of borderline psychopathology, are building blocks for recovery. A new era is under way in which the treatment of BPD can be undertaken with better informed and justifiable optimism and with more appreciation that such treatments rely on coordination of multiple modalities provided by motivated clinicians with special training.

There is now a clearly emerging need to integrate the useful earlier concepts of BPD and the role of psychoanalytically derived therapies with the expanded knowledge about the course, etiology, and other treatments of this disorder. In this chapter, we review these developments and attempt to put the various modalities into perspective.