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Identity Disturbance in Borderline Personality Disorder

Identity Disturbance in Borderline Personality Disorder

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Published by Restroom Chemistry
Study investigating identity disturbance in BPD patients, clinical manifestations, investigation and speculation about the subject. Mentions diagnostic difficulties with BPD populations, attempt to better define/refine the constellation of ID-disturbance in borderline patients with regard to measures, theories, diagnostic measures and interpretation of self-reported experience of the disturbance. Somewhat limited study with much exegesis and speculation.
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Am J Psychiatry 157:4, April 2000
Study investigating identity disturbance in BPD patients, clinical manifestations, investigation and speculation about the subject. Mentions diagnostic difficulties with BPD populations, attempt to better define/refine the constellation of ID-disturbance in borderline patients with regard to measures, theories, diagnostic measures and interpretation of self-reported experience of the disturbance. Somewhat limited study with much exegesis and speculation.
-
Am J Psychiatry 157:4, April 2000

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Published by: Restroom Chemistry on Jan 22, 2009
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05/29/2013

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528
Am J Psychiatry 157:4, April 2000 
Identity Disturbance in Borderline Personality Disorder:An Empirical Investigation
Tess Wilkinson-Ryan, A.B., andDrew Westen, Ph.D.
Objective:
Identity disturbance is one of the nine criteria for borderline personality dis-order in DSM-IV, yet the precise nature of this disturbance has received little empirical at-tention. This study examines 1) the extent to which identity disturbance is a single con-struct, 2) the extent to which it distinguishes patients with borderline personality disorder,and 3)the role of sexual abuse in identity disturbance in patients with borderline personal-ity disorder.
Method:
The authors constructed an instrument that consisted of 35 indicatorsof identity disturbance culled from relevant clinical and theoretical literature and asked cli-nicians to rate a patient on each of the items. The patient group consisted of 95 subjectsdiagnosed with borderline personality disorder (N=34), another personality disorder (N=20), or no personality disorder (N=41). Relevant diagnostic, demographic, and develop-mental history data were also collected. The authors used factor analysis to ascertainwhether identity disturbance is a unitary construct and then examined the relation betweendimensions of identity disturbance and borderline diagnosis after controlling for sexualabuse history.
Results:
Four identity disturbance factors were identified: role absorption (inwhich patients tend to define themselves in terms of a single role or cause), painful inco-herence (a subjective sense of lack of coherence), inconsistency (an objective incoherencein thought, feeling, and behavior), and lack of commitment (e.g., to jobs or values). All fourfactors, but particularly painful incoherence, distinguished patients with borderline person-ality disorder. Although sexual abuse was associated with some of the identity factors, par-ticularly painful incoherence, borderline pathology contributed unique variance beyondabuse history to all four identity disturbance factors. The data also provided further evi-dence for an emerging empirical distinction between two borderline personality disordertypes: one defined by emotional dysregulation and dysphoria, the other by histrionic char-acteristics.
Conclusions:
Identity disturbance is a multifaceted construct that distinguishespatients with borderline personality disorder from other patients. Some of its componentsare related to a history of sexual abuse, whereas others are not. Identity disturbance ap-pears to be characteristic of borderline patients whether or not they have an abuse history.
(Am J Psychiatry 2000; 157:528–541)
I
dentity disturbance is one of the nine criteria for bor-derline personality disorder in DSM-IV, yet its precisenature has received surprisingly little empirical atten-tion. The major theoretical and clinical descriptions of identity confusion in borderline personality disordercome from the psychoanalytic literature, in which the-orists have used terms such as fragmentation, bound-ary confusion, and lack of cohesion to describe the ex-perience of self in borderline personality disorder.These concepts are difficult to operationalize, however,and several questions remain, such as the extent towhich identity disturbance is a unitary phenomenon,the extent to which it distinguishes patients with bor-derline personality disorder from patients with otherpersonality disorders, and the extent to which it is re-ducible to dissociative experiences seen in borderlinepatients with a history of sexual abuse. The goal of thisinvestigation is to explore the precise nature of identity
Received May 7, 1999; revision received Aug. 30, 1999;accepted Nov. 1, 1999. From the Department of Psychiatry, Har-vard Medical School, Boston; and The Cambridge Hospital/Cam-bridge Health Alliance, Cambridge, Mass. Address reprintrequests to Dr. Westen, Center for Anxiety and Related Disorders,Department of Psychology, Boston University, 648 Beacon St., 6thFloor, Boston, MA 02215; dwesten@bu.edu (e-mail).Supported by a grant from the Research Advisory Board of theInternational Psycho-Analytic Association.The authors thank Carolyn Zittel for her help in developing itemsfor the identity disturbance measure; and Dr. Daniel Gilbert, Dr.Sheldon White, and the members of our research laboratory fortheir comments on an earlier draft of this article.
 
Am J Psychiatry 157:4, April 2000 
529
TESS WILKINSON-RYAN AND DREW WESTEN
disturbance in patients with borderline personality dis-order by discovering what types of identity phenomenadiscriminate between patients with and without bor-derline personality disorder while controlling for his-tory of sexual abuse.
IDENTITY: MEANING AND MEASUREMENT
The major theorist of identity is Erik Erikson (1, 2),who popularized the term in his discussion of identitycrises in adolescence. According to Erikson, identityincludes role commitments, a sense of personal same-ness or continuity over time and across situations, asense of inner agency, and some acknowledgment of one’s role commitments and views of oneself by thebroader community. Erikson argued that adolescentsin many cultures experience a period of identity crisis,from which they emerge with some balance betweenidentity achievement and identity confusion. A healthyidentity includes the ability to choose an appropriateavenue for industry, achieve intimacy with another,and find a place in the larger society.The opposite pole of identity is identity confusion,which Erikson originally called identity diffusion. Iden-tity confusion manifests itself in a number of ways: 1)in a subjective sense of incoherence; 2) in difficultycommitting to roles and occupational choices; and 3) ina tendency to confuse one’s own attributes, feelings,and desires with those of another person in intimate re-lationships and hence to fear a loss of personal identitywhen a relationship dissolves. Some individuals escapethis state by choosing a “negative identity” (i.e., a rolethat is inappropriate or unusual given the individual’sattributes, such as race or socioeconomic status) thatoften constitutes a role or group identification nega-tively viewed by the broader culture.Reviewing both the empirical and theoretical litera-ture on self and identity, Westen (3, 4) summarized themajor components of identity as being a sense of con-tinuity over time; emotional commitment to a set of self-defining representations of self, role relationships,and core values and ideal self-standards; developmentor acceptance of a world view that gives life meaning;and some recognition of one’s place in the world bysignificant others.The major research on identity reflects the work of  James Marcia (5, 6), who operationalized Erikson’stheories into “identity statuses” or types. Marcia dis-tinguished four identity statuses: identity achievement,moratorium, foreclosure, and identity diffusion. Foridentity achievement, a person must have struggledwith issues of family, profession, religion, and valuesand have come to some kind of committed resolution.A person who falls into the moratorium category hasput off resolution of identity issues and remains in anextended state of identity search. Foreclosure is the la-bel assigned to people who have made major role com-mitments without ever seriously considering alterna-tive possibilities or experiencing any period of struggle;people with a foreclosed identity have chosen a kind of de facto identity. Finally, the most severe identity prob-lems are found in people with identity diffusion, whomay have had multiple identity crises, chosen a succes-sion of careers or religions, or may not even be awareof their lack of a cohesive identity.
IDENTITY DISTURBANCE IN BORDERLINEPERSONALITY DISORDER
Several clinical theorists have attempted to describethe nature of identity disturbance in borderline person-ality disorder. According to Kernberg (7, 8), identitydiffusion in patients with borderline personality orga-nization reflects an inability to integrate positive andnegative representations of the self, much as the pa-tient has difficulty integrating positive and negativerepresentations of others. The result is a shifting viewof the self, with sharp discontinuities, rapidly shiftingroles (e.g., victim and victimizer, dominant and sub-missive), and a sense of inner emptiness. Kernberg alsoemphasized the way defenses that allow patients withborderline personality disorder to remain comfortablewith remarkable inconsistencies inhibit the capacity toform a coherent view of themselves.Adler and Buie (9, 10) described patients with bor-derline personality disorder as suffering from a senseof incoherence and disjointed thinking, feelings of lossof integration, concerns about “falling apart,” and asubjective sense of losing functional control over theself and other forms of “self-fragmentation.” From aself-psychological perspective, these patients lack anability to internalize many aspects of their primarycaregivers that would allow them to develop a cohesivesense of self. Fonagy and colleagues (11) drew uponempirical data with both borderline patients and mal-treated young children to emphasize the failure of pa-tients with borderline personality disorder to developthe capacity to step inside the mind of another and toimagine the way the other experiences the patient. His-torically, social identity theorists such as the symbolicinteractionists (notably George Herbert Mead) empha-sized the extent to which our views of ourselves resultfrom the reflected appraisals of others—that is, fromseeing ourselves in others’ eyes and hence learningabout who we are. To the extent that patients withborderline personality disorder have difficulty seeingthemselves in the mind’s eye of another, they shouldhave difficulty in developing coherent identities.Systematizing the clinical and theoretical literature,Westen and Cohen (12) summarized the major at-tributes of identity disturbance hypothesized to be cen-tral to borderline personality disorder. These include alack of consistently invested goals, values, ideals, andrelationships; a tendency to make temporary hyperin-vestments in roles, value systems, world views, and re-lationships that ultimately break down and lead to asense of emptiness and meaninglessness; gross incon-sistencies in behavior over time and across situations
 
530
Am J Psychiatry 157:4, April 2000 
IDENTITY DISTURBANCE
that lead to a relatively accurate perception of the self as lacking coherence; difficulty integrating multiplerepresentations of self at any given time; a lack of a co-herent life narrative or sense of continuity over time;and a lack of continuity of relationships over time that
leaves significant parts of the patient
s past
depos-ited
with people who are no longer part of the indi-vidual
s life, and hence the loss of shared memoriesthat help define the self over time.The clinical literature on identity disturbance in bor-derline personality disorder provides a rich conceptualfoundation for understanding identity disturbance, butempirical research remains limited (13, 14). A centralissue in understanding identity disturbance in patientswith borderline personality disorder is the relationshipbetween identity disturbance and a history of sexualabuse. Research suggests that 30%
75% of adult andadolescent patients with borderline personality disor-der have reported histories of sexual abuse (15
17). Inaddition, sexual abuse history and dissociative experi-ences are either common in, or diagnostic of, both bor-derline personality disorder and dissociative identitydisorder (18
21). Given the association between sex-ual abuse and dissociation, the high percentage of bor-derline personality disorder patients with sexual abusehistories raises questions about whether identity dis-turbance is really characteristic of borderline personal-ity disorder or rather of a history of severe and perva-sive sexual abuse.The present study represents an empirical examina-tion of identity disturbance with two aims: to clarifythe construct of identity disturbance and to try to dis-cern the features of identity that distinguish patientswith borderline personality disorder from other psy-chiatric patients.
METHOD
Procedure 
Respondents for this study were experienced psychologists, psy-chiatrists, and social workers. The use of clinicians (rather than pa-tients) as respondents is a growing practice in psychiatric research(22
24). Aside from substantially increasing the numbers of patientswho can be included in a study (and hence increasing generalizabilityand power), the use of clinicians has several advantages. Clinicianstend to be sophisticated observers, who see a patient longitudinallyand can often offer more informed and potentially less biased judg-ments than patients themselves or interviewers who see the patientfor 90 minutes or less. Clinicians can, of course, be biased by theirtheoretical preconceptions; however, all observers have theories andhence potential biases, such as the intuitive theories patients holdabout themselves (that is, their conscious self-concepts, throughwhich their answers to the standard questionnaires and structuredinterviews are always filtered). The question, then, is whether, in agiven research domain, self-report biases or clinician-report biasesare likely to be greater. Four factors led us to prefer trained observersas our informants: 1) the absence of shared theories about the multi-dimensional nature of identity disturbance that could produce bias;2) the possibility of drawing from clinicians with diverse training ex-periences (psychiatrists, psychologists, and social workers) whowould not likely share the same biases; 3) prior research that hadused this method and demonstrated that clinicians do not tend torely on diagnostic prototypes in describing their patients but insteadtend to describe what they see clinically (23, 24); and 4) the prob-lematic nature of asking patients about phenomena such as theirconflicts over ethnicity, gross inconsistencies between what they sayand what they do, and the tendency to define themselves in terms of extreme groups or roles.Clinicians were given a diagnostic/demographic/developmentalhistory form adapted from previous studies (23, 24) and an identitydisturbance questionnaire designed expressly for the purpose of thisresearch.We solicited data from clinicians at The Cambridge Hospital/Cam-bridge Health Alliance at Harvard Medical School by contacting staff and trainees by mail and internal e-mail, which yielded descriptionsof 50 patients. Clinicians were paid a token honorarium of $10. Weinitially planned to include only female patients (to minimize heter-ogeneity, given the high percentage of women among patients withborderline personality disorder in the population); to limit the pa-tient group to those who had been in psychotherapy for less than ayear (to ensure that major symptoms had not changed with treat-ment); and to limit the patient group to those between theages of 18and 40 (again to limit heterogeneity). After it became clear that thiswould not yield a large enough study group, we expanded our crite-ria by 1) eliminating gender and age restrictions, 2) including pa-tients seen up to 2 years in treatment, and 3) not predeterminingwhether the clinician should describe a patient with borderline per-sonality disorder. In addition, we added a second cohort of clinicians(N=45) who completed questionnaires at a workshop on personalityorganization in Washington, D.C. With these modifications, we ob-tained our intended study group size, which we had preselectedbased on power considerations. Clinician respondents were, on theaverage, quite experienced, with mean of 18.13 years (SD=11.09) of clinical experience. They also knew the patients well; the median
TABLE 1. Demographic and Clinical Characteristics of 95Patients Receiving Psychotherapy
a
CharacteristicN%GenderMale3031.6Female6568.4Ethnicity (N=94)Caucasian7781.1Black88.4Latino55.3Other44.2Socioeconomic levelPoor99.5Working class1313.7Middle class5962.1Upper class1414.7Axis I diagnosisMajor depression3233.7Dysthymic disorder2728.4Posttraumatic stress disorder (PTSD)1212.6Anxiety disorder (other than PTSD)1818.9Abuse historyPhysical2627.4Sexual2425.3Any abuse3637.9Confirmation of abuse history (N=28)
b
Acknowledgment by family member517.9Admission by perpetrator310.7Involvement of social service agencies27.1Intervention by legal authorities13.6Victim sent to doctor27.1Patient had conscious memories of abuse at thestart of therapy2175.0
a
Ninety-five clinicians each submitted information on one patientwhom they had been seeing in psychotherapy for at least foursessions but no longer than 1 or 2 years.
b
Includes 24 patients rated as having a sexual abuse history plusfour whose sexual abuse history was rated “unsure”
 
by clinicians.

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