Borderline and Other Personality Disorders: New Directions in 2022

Dev Psychopathol 2009; 21: 1355–1381

The precise nature and etiopathogenesis of borderline personality disorder (BPD) continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core features of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD, with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based on recently accumulated data. In particular, we suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization, linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people’s mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients’ propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed.

Copyright 2009 Cambridge University Press. Reproduced with permission.

Psychotherapy (Chic) 1998; 35:163–176

This study investigates the relationship between therapy attendance with DSM-IV criteria for the cluster B personality disorders (antisocial [ANPD]; borderline [BPD]; histrionic [HPD]; and narcissistic [NPD]). Ninety patients who were found to meet DSM-IV criteria for an Axis II disorder (cluster A personality disorders=10; ANPD=20, BPD=25, HPD=5, NPD=14; cluster C personality disorders=16). Total number of DSM-IV criteria for BPD (r=.33, p=.001) and ANPD (r=.22, p=.04) were significantly related to the number of psychotherapy sessions attended by a patient. Stepwise regression indicated that the 5 individual criteria BPD-1, NPD-4, BPD-8, HPD-8, and ANPD-7 (in order of entry into the regression equation) were independent and nonredundant predictors that explained 31% of variance found in the number of psychotherapy sessions attended by patients. The presence or absence of 3 of these individual criteria provided a good balance of positive predictive power (.78–.95) and overall correct classification rate (.53–.69) for therapy continuation. Clinical and research implications of personality characteristics are discussed in relation to the termination and continuation of psychotherapy.

Copyright 1998 American Psychological Association. Reproduced with permission.

Annual Rev of Clin Psych 2010; 6:421–446

We review the literature on pathological narcissism and narcissistic personality disorder (NPD) and describe a significant criterion problem related to four inconsistencies in phenotypic descriptions and taxonomic models across clinical theory, research, and practice; psychiatric diagnosis; and social/personality psychology. This impedes scientific synthesis, weakens narcissism’s nomological net, and contributes to a discrepancy between low prevalence rates of NPD and higher rates of practitioner-diagnosed pathological narcissism, along with an enormous clinical literature on narcissistic disturbances. Criterion issues must be resolved, including clarification of the nature of normal and pathological narcissism, incorporation of the two broad phenotypic themes of narcissistic grandiosity and narcissistic vulnerability into revised diagnostic criteria and assessment instruments, elimination of references to overt and covert narcissism that reify these modes of expression as distinct narcissistic types, and determination of the appropriate structure for pathological narcissism. Implications for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the science of personality disorders are presented.

Copyright 2010 Annual Reviews. Reprinted with permission.

Am J Psychiatry 2007; 164:1333–1339

This report describes an intensive psychodynamic psychotherapy that the author conducted with a patient with borderline personality disorder named “Ellen.” Dr. Bateman, one of the founders of mentalization-based treatment, and Dr. Kernberg, the founder of transference-based psychotherapy, comment on the treatment, emphasizing the overlapping and distinctive aspects of the two forms of therapy. Each was asked to comment independently and then asked again to offer additional comments on issues that the other had brought up. As such, Ellen’s case illustrates alternative perspectives about psychotherapy with patients with borderline personality disorder. This report offers vignettes derived from six time points in Ellen’s therapy: the time of referral, 3 months later, 11 months later, 4 years later (when the therapy effectively ended), and from follow-up at year 7.

Copyright 2007. Reprinted with permission.

Am J Psychiatry 1996; 153:752–758

OBJECTIVE: This article describes the clinical and theoretical significance of intolerance of aloneness for patients with borderline personality disorder. It is intended to make their treatment more effective and less burdensome.

METHOD: Clinical observations from the author’s more than 9,000 hours of psychotherapeutic work and 500 psychotherapy consultations with borderline patients are synthesized with findings of relevant empirical studies and attachment theory.

RESULTS: Intolerance of aloneness is a deficit that is associated with the borderline patient’s typical clinging and attention-seeking or detached forms of attachment. Suggestions are given for ways in which clinicians can respond to these dysfunctional attachment behaviors to diminish the patient’s feared aloneness without encouraging unnecessary regressions. A framework for understanding the long-term attachment processes required to correct this deficit is offered.

CONCLUSIONS: Intolerance of aloneness is a core deficit in borderline patients that can become less handicapping with reliable, but not excessive, responsiveness of the therapist.

Copyright 1996. Reprinted with permission.

Am J Psychiatry 2009; 166:1365–1374

OBJECTIVE: The authors sought to evaluate the clinical efficacy of dialectical behavior therapy compared with general psychiatric management, including a combination of psychodynamically informed therapy and symptom-targeted medication management derived from specific recommendations in APA guidelines for borderline personality disorder.

METHOD: This was a single-blind trial in which 180 patients diagnosed with borderline personality disorder who had at least two suicidal or nonsuicidal self-injurious episodes in the past 5 years were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. The primary outcome measures, assessed at baseline and every 4 months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes.

RESULTS: Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in borderline personality disorder symptoms, symptom distress, depression, anger, and interpersonal functioning. No significant differences across any outcomes were found between groups.

CONCLUSIONS: These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.

Copyright 2009. Reprinted with permission.