Editorial

Borderline Personality Disorder

B orderline personality is a serious psychiatric disorder, with a prevalence of about 4%

in the community, but as high as 20% in many clinical psychiatric populations, and signif-
icant morbidity. It is difficult to treat (both in the sense of responding poorly and as
personally troubling to the therapist and the treatment team) and poorly understood.
However, we have made tremendous strides in only a few decades, beginning with a theo-
retical concept in psychoanalysis that was ridiculed by most other psychiatrists, and pro-
gressing to a widely recognized clinical entity; from a pejorative label for disliked patients
to a carefully defined diagnostic category; from the subject of almost no systematic study
to one of the most intensively researched personality disorders—in terms of diagnosis, ep-
idemiology, genetics, developmental psychology, biological correlates, pathophysiology,
and treatment—and perhaps most important, from a hopeless prognosis to a hopeful one,
and particularly one for which we have several evidence-based effective treatments.
That is the good news, but there is also much
that is not yet good news—questions to be an-
swered and things that we have yet to learn. There “We have made tremendous
is also the residue of professional bias against the strides in only a few
diagnosis and, unfortunately, stigma for those
who suffer from it, that has hampered progress in
decades...in terms of
the field. This issue of The American Journal of diagnosis, epidemiology,
Psychiatry includes papers that advance the dia- genetics, developmental
logue by exploring our current understanding of
the borderline concept.
psychology, biological
correlates, pathophysiology,
Diagnosis
and treatment.”
There are two quite different notions of the
clinical meaning of the term “borderline.” The
older one, that goes back to its earliest use in the psychoanalytic literature, refers to a
broad category of patients whose underlying psychology does not have the chaos, dis-
organization, or defect in reality testing associated with psychotic patients, but also
lacks the integration, stability of relationships, and regulation of affect associated with
neurotic patients (1). This is, in terms of severity, a middle group between psychosis and
neurosis, diagnostically linked to more severe personality disorders and shifting, unsta-
ble, or polysymptomatic presentations of axis I disorders. Importantly, it is defined by
underlying psychologic structure, not by surface phenomenology.
The second meaning of borderline, “official” in current psychiatric nosology (DSM-
III, DSM-III-R, and DSM-IV) is of a specific axis II cluster B disorder, one which encom-
passes many of the characteristics of the first meaning but particularly as they appear in
histrionic personalities, and which is defined (as is standard in the DSM) by surface
phenomenology rather than underlying psychologic structure. Essentially all of the sec-
ond type of borderline would be included in the first type. However, a number of the
first type would be classified in the DSM axis II system as histrionic, narcissistic, antiso-
cial, cluster A or C, or, quite often, not otherwise specified. Most American psychiatrists
have a fuzzy notion, somewhere between the two, with the psychoanalytically oriented
being closer to the first view and the others being closer to the second.

Etiology
A second theme in the literature on borderline personality concerns etiology. Once
again there have been two distinct views. The first, popular among psychotherapists and

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many early psychoanalytic thinkers, emphasized early experience—pre-oedipal and

separation-individuation were common terms. Parental care had been unempathic,
there had been traumatic experiences, the mother-child “match” was poor, etc. A second
theme, popular among psychiatric researchers, emphasized constitutional factors—ge-
netic links to bipolar or affective disease, temperamental characteristics such as impul-
sivity or affective dysregulation, brain abnormalities, etc. Currently there have been sev-
eral efforts to meld these two perspectives, as is occurring in other areas of psychiatry.
Parents who may have little difficulty raising a temperamentally well-modulated infant
may face major challenges with a dysregulated one, with unempathic and traumatic in-
teractions resulting. Endogenous affective storms may interfere with the normal devel-
opment of internalized object relations. In sum, development is complicated, always in-
volves the interaction of nature and nurture, and although in extreme cases one or the
other may predominate as the determinant of pathology, there is much more likely to be
a complex interaction when the outcome is less extreme—that is, borderline.
Both the restricted, “surface” descriptive diagnosis of the borderline personality dis-
order, and the broader, “deep structure” psychodynamic concept present significant
problems. The descriptive criteria of borderline personality disorder, in practice,
present with a comorbidity with other severe personality disorders of approximately
60%, which points to underlying common personality features. The psychodynamic
definition, originally based on hypotheses regarding common unconscious, early in-
fancy- and childhood-derived conflicts, has defied efforts at precise clinical description,
in addition to its lack of empirical research support. Clinically, it is undeniable that sim-
ilar “surface” personality traits may correspond to different “deeper” psychological
meanings: social timidity, for example, may be a reaction formation against exhibition-
ist trends, an expression of paranoid tendencies, or a schizoid symptom. The search for
the relationship between surface features and underlying psychological or neurobio-
logical structures lends itself to reductionist shortcuts that do not do justice to the com-
plexity of psychopathological conditions.
A major stumbling block for further progress in the construction of a borderline per-
sonality category is the temptation to consider personality disorders as reflecting either
underlying neurobiological structures, or psychological structures disconnected from
their neurobiological roots. In the case of borderline personality disorder, hypersensi-
tivity to negative stimuli and excessive activation of negative affect, linked to hyperac-
tivity of the amygdala and related structures of the limbic system, and, at the same time,
a lack of the capacity for cognitive contextualization and affect control, linked to de-
creased functioning of the prefrontal and preorbital cortex and the anterior cingular
area, represent significant neurobiological correlates of this pathology. From this per-
spective, the descriptive symptoms of borderline personality disorder would express
this pathology of brain systems and the consequential behavioral interactions with the
environment under the influence of this pathology. From a psychodynamic viewpoint,
the common features of borderline personality disorder, and of the severe personality
disorders that are frequently comorbid with it, would be a lack of integration of the con-
cept of self, caused by the lack of integration of self-representations and of object-rep-
resentations under contradictory loving and hateful affect states. The patient’s subjec-
tive life, therefore, remains contradictory and chaotic, with severe identity problems,
and a closely related incapacity to integrate the perception of significant others, thus
motivating discontinuous, chaotic, contradictory social behavior. Both of these neuro-
biological and psychological structural assumptions correspond to clinical and empiri-
cal research data, but we still have to clarify how neurobiological disposition and struc-
tures relate to psychological development and its derived structures.

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Treatment
The concept of borderline was initially developed to explain a group of patients who
had at first been seen as appropriate candidates for psychodynamic psychotherapy—
troubled but not psychotic, and having a wide range of strong affects and intense rela-
tionships. However, they got worse rather than better in the unstructured settings of
such therapy. This led to attempts to develop strategies for identifying such patients be-
fore they had entered psychotherapy—psychological tests, structural interviews, and
diagnostic criteria. These were accompanied by strategies for modifying “classical” psy-
choanalysis or psychoanalytic psychotherapy so that it might be more useful for these
patients, including more active therapists, a greater focus on the patient-therapist rela-
tionship in the “here and now,” the utilization of countertransference responses to ex-
plore the relationship, educating patients to recognize their affective reactions and
what triggers them, to connect actions with thoughts and feelings, both their own and
others, and to regard behavior as motivated, reflecting intentions and desires. This has
led not only to modifications in the treatment of borderline patients, but to a reconsid-
eration of our technique of therapy with other patients as well.
The polarity of neurobiological and psychodynamic viewpoints also permeates ques-
tions regarding alternative treatment strategies with borderline patients. The develop-
ment of our knowledge regarding genetic and constitutional predisposition to excessive
activation of negative affects, temperamental dispositions that influence early object
relations, and the lack of adequate contextualization and control of primitive affects de-
rived from inadequate prefrontal cortical functioning has stimulated the search for bi-
ological treatments directly influencing the activation and intensity of affect. The fre-
quent development in borderline patients of characterologically based depression, rage
attacks and affect storms in general, pervasive anxiety, and dissociative symptoms has
stimulated the utilization of anxiolytic, antidepressant, and mood stabilizing drugs,
and, more recently, the use of low-dose atypical neuroleptics.
The most important finding, perhaps, has been that some borderline patients re-
spond to one or another of a broad spectrum of medications, although only approxi-
mately 30% of these patients respond satisfactorily over an extended period of time. Af-
ter many months of treatment, many patients who initially responded favorably to
medications tend to experience a loss of the effectiveness of drugs, and the underlying
structural predisposition to their affective symptomatology seems to override the ef-
fects of medication. It would seem that, at this time, the major role of medication is that
of an auxiliary treatment tool in the context of a psychotherapeutic treatment.
Recently we have seen the emergence of systematic studies of the efficacy and mech-
anism of action of several different psychotherapies with these patients. These efforts
are in their infancy, but it is already apparent that this kind of research is possible and
that it has much to offer. Several of the treatments are effective and, interestingly, their
patterns of specific effects may differ. This could lead to a rational strategy for prescrib-
ing optimal treatment for specific patients and to the development of new and im-
proved treatments. It also serves as a model for psychotherapy research in general. Dia-
lectic behavior therapy, a specific cognitive behavior therapy, has proven effective, and
constitutes a major practical approach to the treatment of borderline patients, perhaps
particularly those with prevalent suicidal and parasuicidal symptoms and affect dysreg-
ulation. Several psychodynamic psychotherapies also have been demonstrated to be ef-
fective, including transference-focused psychotherapy and mentalization-based psy-
chotherapy. Early evidence indicates that they may operate by specific mechanisms
that differ from each other. Biological and psychotherapeutic approaches probably af-
fect different points in the chain of events that characterizes the psychopathology of
borderline patients.
A major shortcoming of present day research in the treatment of borderline personal-
ity is the limited time span of randomized, controlled, clinical trials, contrasting with

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the widespread clinical impression that long-term treatments are essential for these pa-
tients. A gradually emerging finding is that while the major symptoms that define bor-
derline personality disorder in the description of the DSM or ICD respond relatively
quickly to well-structured specific forms of cognitive behavior or psychodynamic psy-
chotherapy, basic underlying chronic personality dispositions may remain unchanged.
Borderline patients, 20 or 30 years after completion of treatment, still show impoverish-
ment of their personality: a lack of effectiveness and satisfaction in their lives, in their
work and professions, and a lack of stability in intimate love and sexual relationships, in
establishing families, and difficulty overcoming social isolation. The focus on the long-
range course of borderline psychopathology and the effect of interventions on modify-
ing it constitute a major challenge for future research.
The study of the effectiveness of treatment so far has focused mostly on the descriptive
symptoms of the DSM and ICD classifications of borderline personality disorders, and
much less on the subtle and permanent features of their difficulties in work, love, social
life, and creativity. The present-day prevalent instruments for evaluating degrees of psy-
chopathology and symptomatic change have not yet been geared to those fundamental
aspects of personality functioning that determine the long-term satisfaction and effec-
tiveness of a person’s life project. This is a major area, we believe, for future research.
Finally, the relationships between clinical symptoms, deeper psychological struc-
tures, and underlying neurobiological systems are, as yet, to be explored. More subtle
and precise relationships, for example, between affect processing by different brain sys-
tems and the development of psychological defensive operations to deal with conflict-
ual affects will require the development of new research methods. As one illustration of
these relationships that calls for further exploration, it appears that there is no capacity
in the amygdala to combine positive and negative affects, while at the level of the lim-
bic-cortical brain area, the possibility of such integration and mutual toning down of
contrasting affects in the context of cognitive integration exists. At the same time a key
mechanism of change in psychodynamic psychotherapies may be related to the cogni-
tive integration of mutually split-off internalized, affectively invested object relations.
This cognitive integration, however, may only be effective in the context of affectively
invested relations in the patient-therapist interaction. These two, psychological and
neurofunctional processes of affect activation and modification, are presumably re-
lated. How to understand this relationship illustrates one of the many research ques-
tions in the present challenge to link neurobiological and psychodynamic research.
Borderline patients have long been to psychiatry what psychiatry has been to medi-
cine—a subject of public health significance that is underrecognized, undertreated, un-
derfunded and stigmatized by the larger discipline. As with psychiatry and medicine,
this is changing. New knowledge, new attitudes, and new resources promise new hope
for persons with borderline personality.

Reference

1. Kernberg OF: Borderline Conditions and Pathological Narcissism. New York, Jason Aronson, 1975

OTTO F. KERNBERG, M.D.

ROBERT MICHELS, M.D.

Address correspondence and reprint requests to Dr. Michels, Department of Psychiatry, Cornell University Medical
College, 418 East 71st St., Suite 41, New York, NY 10021; [email protected] (e-mail). Editorial accepted
for publication February 2009 (doi: 10.1176/appi.ajp.2009.09020263).

The authors report no competing interests.

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