Am J Psychiatry 157:4, April 2000
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
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.
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
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)
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
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.
Includes 24 patients rated as having a sexual abuse history plusfour whose sexual abuse history was rated “unsure”