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Borderline Personality Disorders
Abstract
Four different models of Borderline Personality Disorder (BPD), each based on a different psychopathological theory, have produced manualized treatments and on this basis controlled outcome studies that evidenced their efficacy. It can be argued, on the ground of the comparable results of the outcome studies, that these different treatments share a common mechanism of action related to the same psychopathological kernel of BPD. The hypothesis that such a psychopathological kernel can be described as dissociative and caused by chronic psychological traumatization in the developmental years allows for a synthetic description of the basic psychotherapy processes allegedly shared by the four different models of BPD treatment.
... He describes how the 'dream work' makes a current situation which would provoke anxiety because it revives repressed childhood states of excitation into a dream, thus enabling the expression of it in a disguised form which escapes censorship. More recent advances have considered situations where transformation is not possible and instead the aim is to rid the psychical apparatus of an excess of painful stimuli (Green, 1977) or to use the dream to evacuate states of mind which cannot be metabolized (Segal, 1981). Bion (1962) linked the capacity to dream to the capacity to transform beta elements into alpha elements, to turn inchoate elements into something more coherent, and in that sense the dream performs the same function as the containing mother, of transforming unbearable anxiety into something bearable. ...
In this paper the author suggests that understanding the roots of the subjective sense of time can throw light on the disturbances in psychic time which are found in particular in the more severe pathologies. She introduces the argument that the roots of the development of the sense of time rest on a primitive sense of time she calls 'reverberation time'. By this notion she refers to the particular quality of the earliest 'back and forth' internalized exchange with the mother in which the auditory dimension plays a significant part. Referring to a wide range of literature and clinical examples, the author thus suggests that the subjective sense of time is created by the reverberation between mother and infant. Disturbances in this area will be reflected in the pathological 'arresting' of time which is observed in the different pathologies and, in particular, around the negotiation of the depressive position and the oedipal situation.Extending this argument, the author goes on to suggest that it is the internalization of this experience of 'reverberation' which lies at the heart of the experience of dreaming; she considers that dreaming understood as an internal dialogue points both to its roots in the relationship to the maternal object and to its fundamental role in psychic life. The author concludes that 'reverberation time' is also the building block of a psychoanalysis, leading to 'unfreezing' psychic time and enabling the reconnection of 'here and now' with 'there and then' in a flexible way which promotes open possibilities, and that this takes place via the analyst's reverie, or time of reverberation.
This short paper examines the relationship between borderline psychopathology and various theories regarding the aetiology of this disorder. In the formation of borderline personality organization, distinct structural alterations in personality development are thought to arise from both genetic/neurobiological and environmental/trauma factors. We concur that these variables are instrumental in the formation of borderline personality organization. However, we believe that genetic/neurobiological variables are more closely related to developmental deficits, whereas environmental/trauma factors are primarily associated with either arrested development or regressive phenomenon. Regardless of aetiology, the resultant borderline personality organization disorders may present with comparable symptoms. Further, we hypothesize that the prognosis for response to treatment is related primarily to whether the borderline disorder arises from developmental deficits, arrested development, or regressive phenomena. Diagnostic indicators and treatment considerations for each of the borderline aetiologies are presented.
Das Konzept der Charakterneurose stammt wie der Borderlinebegriff aus der psychoanalytischen Tradition und wurde/wird v.a. von psychodynamisch orientierten Autoren verwendet. Reich und Alexander benutzten in den 20er Jahren erstmals die damäls (und teilweise noch heute) austauschbaren Begriffe „Charakterneurose“ und „neurotischer Charakter“. Im Verständnis von Psychoanalytikern sind diese Begriffe geeignet, die stärker deskriptiven Begriffe Persönlichkeitsstörung, Psychopathie oder abnorme Persönlichkeit zu ersetzen. Man muß sich aber klar machen, daß es sich in der Praxis so verhält, daß diese Begriffe, je nach der theoretischen Grundorientierung des Autors, weitgehend synonym benutzt werden. Auch die Begriffe Persönlichkeit und Charakter sind austauschbar. Der Charakterbegriff ist der ältere, gewissermaßen unmodernere, zeigt aber in der Folge seiner Bevorzugung durch Psychoanalytiker eine stärker dynamische Konnotation. Der Persönlichkeitsbegriff ist demgegenüber eher deskriptiver, scheinbar wertfreier.
In the last several years, there has been a growing interest in the study and understanding of personality disorders. Patients with personality disorders have been part of the clinician’s case load since the beginning of the recorded history of psychotherapy; the general psychotherapeutic literature on the treatment of personality disorders, however, has emerged more recently and is growing quickly. The main theoretical orientation in the present literature is psychoanalytic (Abend, Porder, & Willick, 1983; Chatham, 1985; Goldstein, 1985; Gunderson, 1984; Horowitz, 1977; Kernberg, 1975, 1984; Lion, 1981; Masterson, 1978, 1980, 1985; Reid, 1981; Saul & Warner, 1982). Millon (1981) is one of the few volumes in the area of personality disorders that offers a behavioral focus, and the volume by Beck, Freeman and associates (1989) will be the first to offer a specific cognitive-behavioral focus. This is of interest, in that leading cognitive therapists have been, and remain, interested in “personality disorder” and “personality change” (Hartman & Blankenstein, 1986). When Beck (1963a,b) and Ellis (1957a, 1958) first introduced cognitive approaches, they drew upon the ideas of “ego analysts,” derived from Adler’s critiques of early Freudian psychoanalysis. Though their therapeutic innovations were seen as radical, their earliest cognitive therapies were, in many ways, “insight therapies” in that the therapy was assumed to change a patient’s overt “personality,” whether or not the therapy changed some hypothesized underlying personality. Although Beck and Ellis were among the first to use a wide array of behavioral treatment techniques, including structured in vivo homework, they have consistently emphasized the therapeutic impact of these techniques on cognitive schemata and have argued in favor of the integration of behavioral techniques into therapy within a broad framework that has some roots in prior analytic practice (Beck, 1976; Ellis & Bernard, 1985); they and their associates have emphasized the impact of treatment for particular types, or styles, of cognitive errors on dysfunctional self-concepts, as well as on presenting focal problems (Beck & Freeman, 1989; Ellis, 1985; Freeman, 1987).
After reviewing the history of conceptual and procedural changes in borderline patients, the author pointed out that the recent emphasis on the aggression and its origination in infancy in its treatment seems to blur the developmental issues in pre-adolescence and adolescence and to present difficulty in concluding the treatment. And a borderline case of the patient, a 20–year-old single woman with various symptoms, was presented. An examination of the course of treatment revealed that in order to better understand the process of therapeutic change it would be best to set the third phase with a strong narcissistic coloration between the working-through and separateiontermination phases described by Masterson, J.F. Finally, it was emphasized that this narcissistic phase is a repetition not only found in childhood, but also in the preadolescent development and its disturbances.
Anakin Skywalker, one of the main characters in the "Star Wars" films, meets the criteria for borderline personality disorder (BPD). This finding is interesting for it may partly explain the commercial success of these movies among adolescents and be useful in educating the general public and medical students about BPD symptoms.
Personality disorders (PDs) criteria are still in development. Cloninger's biosocial theory of personality contributed to this discussion. The aim of the study was to explore the relationships between extreme expressions on temperament and an immature character according to Cloninger's assumptions. Eight hundred healthy volunteers and 200 psychiatric inpatients were consecutively recruited each from Sweden and Germany, and were asked to complete the Temperament and Character Inventory, which measures 4 temperament and 3 character dimensions. Patients differed from controls on temperament and character dimensions. The combination of low and very low character scores with extreme scores in either novelty seeking, harm avoidance, or reward dependence was found more often among patients with PD compared with patients without PD and controls; this is more pronounced with an increasing number of extreme temperament scores. The Temperament and Character Inventory represents a useful tool in the diagnostic process of personality disorders.
Highly suicidal, borderline patients are difficult to treat within the hospital and the community. The institution of managed care necessitates that care for these and other chronically hospitalized populations take place in the community. Psychotherapy has shown moderate success for some borderlines, however, treatment attrition is a significant problem. Without an intervention that successfully maintains suicidal borderline patients in therapy, either more costly methods of treatment must be used or death will result. A form of cognitive-behavioral therapy called dialectical behavior therapy has shown a high rate of effectiveness in reducing inpatient hospital days, suicide attempt frequency, and therapy attrition.
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