Borderline Personality Disorder (Medical Psychiatry).pdf

Borderline

Personality

Disorder

edited by

Mary C. Zanarini

Harvard Medical School

Boston, Massachusetts, U.S.A.

McLean Hospital

Belmont, Massachusetts, U.S.A.

New York London

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Preface

Borderline personality disorder (BPD) is both a common and very serious

psychiatric disorder. Recent studies have found that about 2% of American

adults meet criteria for BPD. Perhaps more troubling is the fact that this

diagnosis is associated with high levels of mental health service utilization,

psychosocial impairment, and subjective distress.

The disorder was ﬁrst described by Adolph Stern in 1938, but it did

not enter the ofﬁcial nomenclature of the American Psychiatric Association

until 1980. In the introductory chapter on History of the Concept, we will

review the many psychoanalytic concepts that were used during the 1950s

and 1960s to describe borderline patients (e.g., psychotic character, as-if

personality). The chapter will also review the efforts of descriptive psychia-

try to conceptualize BPD as a subsyndromal version of ﬁrst schizophrenia,

then mood disorders, impulse spectrum disorders, and ﬁnally, traumatic

disorders.

Much of the recent research has focused on the etiology of BPD.

This research has investigated four pathways to the development of BPD.

The ﬁrst of these areas of investigation is environmental factors. Kenneth Silk

reviews the existing literature, which ﬁrst focused on relatively subtle failures in

early parenting, and more recently has focused on frank experiences of neglect

and abuse. This chapter addresses the controversy of whether sexual abuse is

either necessary or sufﬁcient for the development of BPD.

iii

Preface

The second area of etiological research is the role of temperament.

Thomas Widiger reviews the vast literature on the etiological signiﬁcance

of disordered personality to the development of BPD. Emil Coccaro

addresses the third area of etiological research—neurobiological factors that

may underlie the symptomatic expression of BPD and its attendant psycho-

social impairment. Svenn Torgersen addresses the fourth pathway to the

development of BPD—its genetic inheritance.

BPD is often comorbid with a number of other conditions—most com-

monly mood disorders, anxiety disorders, eating disorders, and substance

use disorders. This has led to the unfortunate practice of many borderline

patients being misdiagnosed as suffering from bipolar II disorder. It has also

led to the unfortunate tendency of some therapists to ignore a patient’s bor-

derline personality and instead treat their ‘‘chronic post-traumatic stress

disorder’’—often with serious negative consequences. Bruce Pfohl reviews

the literature on comorbidity and suggests useful ways to correctly identify

and treat comorbid conditions.

Information concerning the longitudinal course of BPD is important

in informing patients and their families about what they can reasonably

expect in the future. It is also important to inform clinicians about the nat-

ural history of the disorder so that they can be as supportive and patient as

needed. To date, 17 small-scale, short-term prospective studies of the course

of BPD have been conducted. Four large-scale, long-term follow-back stud-

ies of the course of BPD have also been conducted. It has been difﬁcult,

however, to generalize from the results of these studies due to a series of

methodological difﬁculties (e.g., failure to use reliable diagnostic interviews

for BPD, high attrition rates, only one follow-up assessment per study).

More recently, two large-scale, long-term prospective studies of the course

of BPD have been funded by the National Institute of Mental Health. The ﬁrst

of these studies—the McLean Study of Adult Development—found that remis-

sions from BPD are far more common than previously recognized and that

recurrences of BPD are extremely rare. Additionally, two different types of bor-

derline symptoms, with different courses, have been identiﬁed. The second of

these studies—the Collaborative Longitudinal Personality Disorders Study—

foundevenhigherratesofremissioninanevenshorterperiodoftime.Taken

together, the results of these ongoing studies suggest that the prognosis for most,

but not all, borderline patients is better than previously recognized.

Andrew Skodol reviews what these different generations of studies

have found concerning the psychosocial functioning of borderline patients.

Mary Zanarini reviews the symptomatic course of BPD (and its treatment

over time). Joel Paris reviews the varying suicide rates found in these studies

(3–10%) and offers suggestions about the assessment of suicide risk and the

handling of crises related to suicidality.

Most borderline patients are in treatment for their disorder and its

attendant level of psychosocial disability. John Gunderson, the ‘‘father’’ of

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