STONE

CLINCIAL TREATMENT GUIDES FOR BPD

Borderline Personality Disorder: Clinical

Guidelines for Treatment

Michael H. Stone

Abstract: Borderline personality disorder (BPD) is fundamentally a syndrome

composed of symptoms (primarily of emotional dysregulation) and a number
of true personality traits (such as inordinate anger, impulsivity, and a tendency
to stress-related paranoid ideation). Whereas schizotypal personality disor-
der, with its cognitive peculiarities (ideas of reference, odd beliefs, eccentric
speech), is closely linked as a genetic condition—“borderline” to the major
condition schizophrenia—BPD is less closely linked to bipolar disorder. Some
cases of BPD are linked genetically to and are in the “border” of bipolar disor-
der. But the condition can also arise from adverse post-natal factors: parental
cruelty or neglect, or incest. In some BPD patients, both are present: risk genes
for bipolar disorder and adverse conditions within the family. The genetic risk
is often overlooked. To avoid this, initial evaluations should always include a
careful and extensive family history for mood disorders, and should extend out
to grandparents, aunts, uncles, and cousins. Where the history suggests a ge-
netic link to bipolar disorder, a mood stabilizer such as lithium or lamotrigine,
even in modest doses, may be particularly beneficial, more so than conven-
tional antidepressants. In some patients, ADHD was present in childhood, BPD
was diagnosed during or after puberty, and a form of bipolar disorder becomes
apparent during their 20s.
As for the psychotherapeutic component, the patient’s cognitive style and
capacity for introspection will help determine whether a primarily expressive
(psychoanalytically oriented) technique is preferable or a primarily cognitive-
behavioral technique. Flexibility is necessary, since during emotional crises,
supportive and limit-setting interventions will be needed, along with psycho-
tropic medications, and where necessary, programs to help combat substance
abuse (which is common among patients with BPD).

Keywords: borderline personality disorder, psychotherapy, genetic factors,

prognostic factors

Michael H. Stone, M.D., Professor of Clinical Psychiatry, Columbia College of

Physicians & Surgeons.

Psychodynamic Psychiatry, 47(1) 5–26, 2019

© 2019 The American Academy of Psychodynamic Psychiatry and Psychoanalysis
6 STONE

Establishing guidelines for the treatment of borderline personality

disorder (BPD) is a particularly daunting task. This is so for a number
of reasons. To begin with, BPD is albeit a psychiatric disorder, not a
true personality disorder in the same sense as, for example, compul-
sive, dependent, or avoidant disorders. The true personality disorders
need not be accompanied by symptom-disorders (such as social anxi-
ety, anorexia, substance abuse, depression), whereas BPD is always
accompanied by identifiable symptom-disorders. The latter of course
have a bearing on what would be the appropriate treatment measures.
Further, because it is not necessary to manifest all the diagnostic de-
scriptors (items) for BPD, many combinations of the diagnostic items
will suffice—as long as patients have the minimum number to establish
the BPD diagnosis—but, as a result, will describe patients who differ
considerably from one another. A patient with identity disturbance,
mood lability, and chronic feelings of emptiness, for example, will dif-
fer considerably from a BPD patient with marked impulsivity, tenden-
cies to self-harm and suicidal gestures, and inordinate anger. The treat-
ment approach will likewise differ considerably. A patient of the latter
type will require much more in the way of limit-setting and medication
than would be necessary for the less action-prone patient. The cogni-
tive style of the patient also figures importantly into the equation. BPD
patients who are highly reflective and introspective may respond well
with a psychodynamic therapy, such as expressive (Gunderson, 2001),
transference-focused psychotherapy (TFP) (Kernberg et al., 1989; Kern-
berg, Yeomans, Clarkin, & Levy, 2008), or mentalization-based treat-
ment (Bateman & Fonagy, 2004). Other BPD patients of a different cog-
nitive style may make better progress with a different modality, such
as dialectic behavior therapy (DBT; Linehan, 1993) or schema-based
therapy (SBT; Young, Klosko, & Weishaar, 2003).
Another important and often neglected consideration pertinent to the
treatment of patients is the genetic factor. Whereas patients with schizo-
typal personality may routinely be understood as within the penumbra
of schizophrenia, and often have schizophrenic relatives, borderline
patients—in a smaller, but still significant percentage of cases—have
relatives in the manic-depressive spectrum, including those with recur-
rent depressive disorders or others within the bipolar spectrum. Many
BPD patients themselves can eventually be diagnosed with either a bi-
polar I or a bipolar II disorder. The latter is characterized as consisting
of hypomanic episodes alternating with severe periods of depression.
The importance of the genetic factor underpinning psychological at-
tributes in general was emphasized recently by Robert Plomin (2018).
He cautions, for example, that, “There is no point at which genetic risk
tips over into pathology. We all have thousands of DNA differences that
 CLINCIAL TREATMENT GUIDES FOR BPD 7

predispose us to schizophrenia; genetic risk depends on how many of

these differences we have. It’s all quantitative…a matter of more or less.
Genetically speaking, there are no disorders, just dimensions” (p. 1). In
this regard, many BPD patients may be understood dimensionally as
within the bipolar spectrum. In order to better to ascertain the degree
of genetic susceptibility, it is important to take a family history in one’s
initial interviews with borderline patients, including if possible two or
three generations of relatives—extending out to grandparents, aunts,
uncles, and cousins. This exercise will be all the more relevant when
assessing those BPD patients who have not been highly traumatized
or sexually molested: In these patients, absent the post-natal (environ-
mental) factors that conduce to the development of BPD, genetic pre-
disposition is apt to weigh more heavily in the balance of contributing
factors. Among the 71 BPD patients I have worked with over the years,
68 were female—13 of whom (19%) had been incest victims. Thirteen
were themselves bipolar and came from families with a history of bipo-
lar relatives. There was an overlap group of six patients who had been
both incest victims and diagnostically bipolar. In my long-term (10- to
25-year) follow-up study of hospitalized borderline patients, 28 of the
145 female patients had been incest victims—the same percentage as
noted in my private-patient series (19.3%). Three of the hospitalized
patients (in what I called the PI-500 study) had later committed suicide
(Stone, 1990), but it was encouraging to note that about half of these 28
patients were doing fairly well at follow-up (with a Global Assessment
Score of 61 to 70 in six cases) or quite well (GAS score 71 or higher). The
incest factor may help account for the lopsided sex distribution among
BPD patients (which is usually at least 3:1 in most series), since females
are much more likely to be victims of incest than men, and the psycho-
logically damaging effects of incest (as well as of other forms of sexual
molestation) often include long-lasting distrust of men (or in some cases
to promiscuity) and thus to the “stormy relationships” that constitute
one of the BPD diagnostic items, as well as to depression. Women are
already more vulnerable to depression than men, while men are more
prone than women to develop what Annett Schirmer called “disorders
of antisocial emotions” (Schirmer, 2013, p. 605). “Mood lability” (often
with episodic depression) is yet another BPD item. The BPD item “inor-
dinate anger” may be linked either to bipolar spectrum psychopathol-
ogy or to having been abused sexually or physically during one’s early
years. Some patients have of course experienced both: the genetically
predisposed mood disorder and the environment-related molestation.
In line with Plomin’s emphasis on a “dimensional” approach to diag-
nosis, I had earlier offered various examples related to the interaction of
the genetic predisposition (depending on its strength) to bipolar spec-
8 STONE

trum disorders and the level of adverse environment (Stone, 2013). Dif-
ferent scenarios were discussed. If, for example, one had a high genetic
risk for bipolar disorder but had grown up in a tranquil, non-abusive
environment, the eventual illness might consist of bipolar disorder
combined with BPD (more likely in female patients). In a similarly tran-
quil home, someone with just moderate genetic risk for bipolar disor-
der might emerge with a bipolar spectrum condition—but without the
BPD. Moderate genetic risk but coupled with an adverse environment
(that might also include incest) would then predispose to the combined
condition: bipolar disorder plus BPD. Absent any significant genetic
risk, however, a highly adverse environment would predispose just to
BPD alone. The section that follows provides examples of BPD patients
from families with varying degrees of genetic risk.

GRADATIONS OF GENETIC RISK FOR SERIOUS MENTAL

ILLNESS: ILLUSTRATIVE EXAMPLES AND TREATMENT
IMPLICATIONS

Patient A was diagnosed with BPD at 22 when she was hospital-

ized shortly after the birth of her son. Her husband of two years had
abandoned her in the middle months of her pregnancy. She reacted to
this with severe depression and suicidal gestures (self-cutting). Three
years earlier, both her parents had committed suicide in a suicide pact
prompted by her father’s business failure. Her father had been diag-
nosed with bipolar I disorder, and her mother had been hospitalized
numerous times with what was called paranoid schizophrenia. She had
been alternatingly rejecting and physically abusive toward her daugh-
ter during her first 12 years, but had then switched to becoming in-
creasingly dependent on her throughout her adolescence. The mother’s
father had been treated for a paranoid disorder, and both of her father’s
sisters had been hospitalized on a few occasions for severe depression.
After leaving the hospital, patient A was able to complete college and
work in the financial industry. In the years that followed, she remained
in psychotherapy and had a series of turbulent romantic relationships,
though she never remarried. Her most prominent borderline features
were mood-lability, inordinate anger, tempestuous interpersonal rela-
tionships, stress-related paranoid ideation, and efforts to avoid aban-
donment. Another prominent abnormality consisted of an inability to
understand and relate properly to social cues, always “saying the wrong
thing,” after the manner of people with Asperger syndrome (i.e., high
functioning within the autistic spectrum disorders). She has continued
 CLINCIAL TREATMENT GUIDES FOR BPD 9

in twice-weekly psychotherapy (initially of a psychodynamic nature;

more recently, primarily supportive). Medications have consisted of an-
tidepressants and anti-anxiety agents, occasionally supplemented with
small doses of an antipsychotic drug (aripiprazole/Abilify) and mood-
stabilizers (lithium and lamotrigine in small doses). A willingness for
sex allowed her to retain close relationships with men for extended pe-
riods, but now in her mid-70s this has no longer been possible. She has
never had close friendships with women, and now is burdened with
loneliness and a diminished capacity for enjoyment. Psychotherapy at
this point is purely supportive, with an emphasis on teaching her, when
meeting someone new, to ask what the other person thinks about some
important topic of the day, rather than blurting out her own view—
which is usually extreme and off-putting, tending only to alienate the
other person and preventing a friendship from developing.
Patient B has been in psychotherapy almost continually since her
mid-teens. Her mother and brother suffered from recurrent depression;
both were also narcissistic and rejecting in their attitude toward her.
The maternal grandfather had carried on an incestuous relationship
with her for the five years between ages eight and thirteen. A paternal
aunt was bipolar. In the aftermath of the incest (which included inter-
course), the patient became morbidly obese as she entered her 20s—
with the conscious idea that by making herself unattractive to men in
that way, she could avoid being taken advantage of. She did eventually
marry, however, and had three children (all boys). The eldest son had
attention-deficit disorder with hyperactivity in adolescence, culminat-
ing in a distinct bipolar I disorder as he entered his 20s. The middle son
was diagnosed with BPD in late adolescence, largely because of his im-
pulsivity, angry outbursts, and mood lability. He also abused halluci-
nogens. I began working with the patient when she was in her mid-30s,
shortly after she was released from the hospital because of a suicide
attempt in the midst of violent arguments with her husband. Treatment
consisted initially of twice-weekly psychotherapy, combining expres-
sive and supportive elements. A highly intelligent and artistically gift-
ed woman, she earned a fair amount of money by painting and selling
portraits. Unusually vulnerable to feelings of abandonment, she react-
ed with intense anger when I was going to miss a few sessions in order
to give lectures outside the city. This issue was eventually resolved, and
the therapy became more supportive, focusing on conflicts relating to
her children. The two older boys were contemptuous of her because of
her obesity. They knew nothing about her incest history, and remained
judgmental and unsympathetic. At my urging, she underwent bariatric
surgery and lost over 100 pounds. She was then less depressed, but still
limited in her functioning due to the obesity-related arthritic problems
10 STONE

in her legs. Several medications had proven helpful: antidepressants

(chiefly fluoxetine), mood-stabilizers (oxcarbazepine/Trileptal and
lithium), and—during spells of anxiety—clonazepam. Her relationship
with her husband had improved markedly. And during her sessions,
she now dwelled less on issues relating to herself and more on the con-
tinuing problems with her children.
Patient C came from a family where the genetic predisposition to bi-
polar disorder was notable but where the negative environmental fac-
tors were of only moderate proportions. Both parents were profession-
als, and both were given to episodic depressions of marked severity. The
maternal grandfather was a short-tempered and at times violent man.
He was considered bipolar but whose manic episodes were marked by
extreme irritability rather than by exaggerated cheerfulness. Her older
sister had been hospitalized in mid-adolescence for depression and
suicidality, and was diagnosed with BPD. Patient C was more sociable
and more readily likeable than the other members of her family. While
still in graduate school, she married a man who proved to be dour and
uncommunicative. After three years, divorce seemed unavoidable; she
made a suicide attempt with a drug overdose and had to be briefly
hospitalized. I began treating her just after her release from the hospi-
tal. The pertinent BPD criteria were her impulsivity, suicidal behaviors,
mood lability, stormy relationships with men, and fear of abandon-
ment. In her first dream, she saw herself in a hospital bed, mortally ill;
a doctor enters her room. He is quite drunk but reassures her by saying:
“Donchu worry, yer gonna be aw-right.” The transference implications
were clear: I was no more reliable than her father (who abused alcohol).
As she came to trust me more in the months that followed, she now
felt she had an ally—someone who would be there for her as she went
ahead with the divorce. She did however make one suicide gesture via
reckless driving when she separated completely from her husband. The
focus in therapy was then on her insecurity and low self-regard that led
her to engage in brief affairs with a number of different men. Her at-
tractiveness made it easy for her to find them, but she tended to choose
men who treated her shabbily. The men were often much older, and
she came to understand that they were father-substitutes who were not
more caring or reliable, as it turned out, than her own father. She expe-
rienced periods of depression as each of these relationships foundered.
Antidepressants offered some relief during this time. After two years,
her level of self-confidence improved; she then met a man, a promising
young professional whose affection for her was genuine. They married,
and she has enjoyed a satisfying life with him for over 20 years, work-
ing productively and raising their two children. She would no longer
be considered borderline.
 CLINCIAL TREATMENT GUIDES FOR BPD 11

Patient D came from a family with a modest degree of genetic pre-

disposition to bipolar disorder, but differed from the previous three pa-
tients, in that she had not experienced any significantly adverse post-
natal factors. She was one of two children raised in an upper middle
class family by affectionate parents, both professionals who were never
neglectful, abusive, rejecting, or otherwise disagreeable. Her father de-
veloped a severe and chronic depression when she was in her early
teens and has worked only sporadically since. Her menarche was at
15. The following year, she became severely depressed and suicidal,
and was hospitalized for what turned out to be the first of a dozen
subsequent admissions for depression and suicide attempts. Although
she had always been a straight-A student, she was unable to finish high
school until she was 20. Along the way, she developed other condi-
tions, most notably anorexia nervosa (with profound weight loss) and
obsessive-compulsive disorder—with a fear of inadvertently harming
others. These fears resembled those described by LeGrand du Saulle
(1883): she left her books on the floor, for example, lest one of them fall
and injure her cat. Occasionally, her depression would be interrupted
by a brief hypomanic episode marked by rapid speech and unaccus-
tomed gregariousness. She was diagnosed with both BPD (especially
because of the self-damaging acts) and bipolar II. Some felt her border-
line disorder was somehow an expression of the underlying bipolar
condition, given that she had none of the adverse environmental fac-
tors that often precede the development of BPD. After release from a
hospitalization in her early 20s, a new psychiatrist focused on what he
saw as narcissistic features, placing less emphasis on medication. Not
long after, she engaged in another episode of self-cutting and was once
again hospitalized. This time, her after-care was conducted by a psy-
chopharmacologist who focused on the bipolar aspects of her condition
and prescribed a combination of lithium and clozapine. The latter was
in response to her failure in the past to benefit from the conventional
antipsychotic medications. With this regimen, she was able to make
substantial improvement. She was able to attend college, achieving
straight A’s as she had done earlier in high school. She was more self-
confident and began dating, though she continued to be self-conscious
about her weight, objectively low as it was, and ate very sparingly. Her
mood was brighter, and for the first time she began to look forward to
what she now saw as a rewarding future.
Patient E was born in Argentina and came to the United States af-
ter the death of her father when she was seven. Apart from a sister
with mild but recurrent depressions and an aunt with bipolar disorder,
the other members of her immediate family did not suffer from mood
or other psychiatric disorders. The family was wealthy, including her
12 STONE

mother’s second husband whom she married when the patient was 10.
The patient idolized her father, who had been a kindly and indulgent
man; his death was the major trauma in her life. Her mother was inor-
dinately strict and at times punitive. During her childhood years, if her
mother felt she had been “naughty,” she would be strapped to a chair
and spanked severely. Her worst punishment came when her mother
caught her and a boy (they were both seven) showing each other their
sexual parts. This set the stage for one of the major symptoms that
emerged during her adolescence, namely, pronounced germ-phobia
and related obsessive-compulsive phenomena. She suffered a break-
down during college, made a suicide attempt with pills, and was hospi-
talized for a lengthy period. Her psychiatrist used a primarily psycho-
analytic approach, focusing on the connection between her equating
sex with sinfulness. Her symptoms persisted after her release to a point
where she could no longer handle money, because it had been touched
by so many people. Clothes and bedding were sent daily to the clean-
ers. Cognitive aberrations developed along similar lines, and this led
from her original diagnoses of BPD and bipolar disorder to BPD and
schizoaffective disorder. Walking in the street past a fat or pregnant
woman made her feel she would somehow become pregnant and fat.
In reaction, she became anorectic and quite slender. She was 30 when I
began treating her. My initial approach was also psychoanalytically ori-
ented. She was very receptive, worked diligently with dream material,
and showed good understanding of the connection between her child-
hood sexual “sinfulness” and her morbid fear of all things “dirty” and
sexual. But the symptoms did not lose their strength. I began to adopt
a more behavior-oriented (and to me, less familiar) approach. I asked
her once, for example, to hold out her hands. I dropped several dollar
bills onto them, and urged her to accept that “you will live to the mor-
row.” Meaning: nothing bad will happen to you. She gradually became
more at ease with handling money and with sleeping several nights in a
row without changing the sheets. She began to date a man she had met
at a social gathering. She gradually overcame her compunctions about
sex. He proposed to her and intimated that he was a man of means.
But this turned out to be untrue: he proved to be more in love with her
family’s money than with her. She broke the engagement, but became
suicidal; her fragility was heightened by her having stopped her anti-
psychotic medication for several weeks while she was away with him.
Upon her return, I restored her medication and went with her to the
emergency room, where after a few hours her suicidal feelings abated.
This was a turning point. During the next several months, she became
less depressed and less symptomatic. She met a much more suitable
(and honorable) man—whom she later married. I have maintained con-
 CLINCIAL TREATMENT GUIDES FOR BPD 13

tact with her over the ensuing 30 years, during which time she raised
a son who is now in college and, after completing training, has been
working effectively in a mental-health profession. She would no longer
be considered either borderline or schizoaffective. Contributing to her
emergence from the severe symptomatology of her earlier years were
the important (and mitigating) factors of her positive personality traits,
such as those emphasized in the five-factor model of Costa and Widi-
ger (2002) and enumerated by Trull and McCrae (2002)—in particular:
agreeableness and conscientiousness (Stone, 1993, pp. 112-130).

GRADATIONS OF SEXUAL MOLESTATION BY FAMILY

MEMBERS AS A RISK FACTOR IN THE DEVELOPMENT OF BPD

I recently provided clinical vignettes of patients with BPD who had

during their childhood (i.e., prepubescent) and adolescent years been
the victims of transgenerational incest (Stone, 2017a). The most com-
mon form encountered was father-daughter. Uncles or grandparents
were the perpetrators in a few of the other cases. Other forms of incest
involving a parent are much less common: father-son, mother-son, and
mother-daughter. In over 50 years of practice (and hospital work), I
have encountered only one instance of mother-daughter incest. This
was a French woman whose mother had abused her when she was a
girl of seven or eight. I encountered her as a woman in her 20s with
suicidal and self-injury tendencies as well as other borderline features.
The inappropriate sexuality of her earlier years seemed to carve out a
path of sexual deviance, and she became involved in the pornography
industry, but she always lived at the mercy of the men who hired her
to take part in porn films. One of the few patients I worked with who
had been the victim of father-son incest in adolescence had been raped
anally by his father. Enormously angry and resentful, the patient iden-
tified as gay, but hated his homosexuality and hated people in general.
He contracted AIDS in one of his rare homosexual contacts and died in
the early 1980s when the epidemic was at its peak. Mother-son incest
was also rare: there were only two cases among the 550 patients in my
PI-500 follow-up study (Stone, 1990). Both later committed suicide. I
have worked with a third such patient (on an ambulatory basis): this
man was eventually able to make an excellent adjustment.
Among the larger group of incest victims were women who had been
abused by an older male relative or, in rarer instances, by several broth-
ers; the psychological damage tended to be worse when the perpetrator
was a father rather than any other male relative. Among the examples
14 STONE

mentioned in my 2017a article, jealousy was a serious problem, since

by its nature, father-daughter incest implies that the father has been
unfaithful to the mother. The question arose in these women: Could a
man, including a husband, ever be trusted? One woman, for example,
had grown up in an impoverished family where the parents divorced,
and she and her father had slept (and had sex) in his car. A quite beauti-
ful woman, she later married a man who went from having a modest
job as a plumber to becoming a highly successful contractor and multi-
millionaire. He proved, however, no more faithful to her than her father
had been to her mother. They divorced. She then began an affair with
a much more wholesome and loyal man—about whom she was never-
theless pathologically jealous. I worked with her in psychotherapy for
two years, after which her jealous tendency appreciably lessened, and
she was able to make a much more stable (and trusting) marriage. This
was one of the very few cases I have ever worked with where a jealous
person was eventually able to make a satisfactory marital relationship.
She showed six of the nine BPD characteristics initially, but later would
no longer meet BPD criteria.
The interplay of adverse factors such as incest—and genetic factors
aside from those that appear to heighten the risk for BPD—needs to
be taken into account. But we know little about the favorable genet-
ic factors that render certain persons relatively invulnerable to early
traumata such as incest. Some favorable genetic factors apparently al-
lowed the jealous woman just mentioned to rise above prolonged fa-
ther-daughter incest, marital infidelity, and jealousy to eventually form
a stable marriage. In contrast, several of the young women in the PI-
500 series committed suicide in their 20s and 30s. One had grown up
as one of eight children in an extremely wealthy family. Her narcis-
sistic father had committed incest with her and two of her sisters, one
of whom had already committed suicide by the time our “P-I” patient
was admitted to our service. She had run away from home, been hos-
pitalized at our unit, eloped after a few months, and briefly became
one of Andy Warhol’s actresses. She made a serious suicide attempt
from which she was rescued, met a man she later married, but soon af-
ter—feeling despondent about not being able to function well as a wife
given her chaotic past—committed suicide. In contrast, another young
woman who had been involved in a father-daughter incest situation
had run away from home in her late teens, become a fashion model,
and then the mistress of a wealthy older man. She later married briefly
and had a child whom, after divorce, she raised herself. When I saw
her in psychotherapy she was in her mid-20s. She showed five of the
BPD criteria and was markedly histrionic and “flighty”—in the sense
that she often skipped sessions, going away with her sister and using
 CLINCIAL TREATMENT GUIDES FOR BPD 15

marijuana and cocaine. She is currently in her mid-50s and is leading a

more tranquil life, living with former high-school friends. Her life has
had some of the characteristics of Marie DuPlessis, the beautiful young
woman from Normandy, who became first the mistress of the novelist
Alexander Dumas, then briefly of Liszt, and finally the wife of a French
count—and the inspiration of Verdi’s La Traviata—before dying of tu-
berculosis at 23 (Weis, 2015).
Although sibling incest is more common than transgenerational
incest, there were no known cases among the patients in the PI-500.
Brother-sister incest is much more common than sister-sister. The latter
is often characterized by mutuality and the absence of force, and for
these reasons, apparently less pathogenic (let alone conducing to the
development of BPD) (Russell, 1986, pp. 49-50). The one instance of
brother-sister incest in my practice occurred 50 years ago and involved
siblings who had been consistently neglected by their parents. In their
teens, they began sleeping together and having sex, each serving as a
kind of surrogate parent as well as close companion for the other. My
patient (the sister) later married and was doing well when I contacted
her after many years in a follow-up effort. But in another case, where I
served as a consultant, a woman had, in effect, been gang-raped by her
four brothers. When she married and later had a daughter and son of
her own, she became convinced, to the point of delusion, that her hus-
band would commit incest with their daughter. She divorced. The two
teenage children preferred to remain with their (non-abusive) father
and were both doing well when I followed up on their situation years
later. Clearly, the hostility and violence of her brothers were the patho-
genic elements in her personality aberration. One needn’t have invoked
a genetic abnormality.
From an etiological standpoint, genetic predisposition to bipolar dis-
order and the post-natal factor of incest are sometimes commingled as
fostering BPD. A former borderline patient of mine, for example, had
been sexually molested by both parents; her father had been hospital-
ized earlier for manic-depression (bipolar I disorder). Her chief BPD
characteristic, besides suicidal gestures and threats, was her inordinate
anger. In her case, the father was the more loving parent, while the
mother was consistently hostile. Though both parents had obviously
taken advantage of her, it was the mother’s dislike and hostility that
seemed the primary cause of my patient’s anger and contempt. She
never spoke ill of her father even though he had also misused her egre-
giously via the incest. The genetic “loading” was great since two pater-
nal uncles had also been diagnosed as bipolar.
When transgenerational incest (especially by a father) is accompa-
nied by sadism, this seems sufficient in and of itself to bring about BPD
16 STONE

in the victim as she (or rarely he) enters adolescence. I had occasion,
when making diagnostic evaluations at a drug-abuse clinic, to inter-
view a woman in her 30s with BPD and multiple drug abuse (alcohol,
marijuana, and cocaine). Her history of incest was the most sordid I had
encountered before or since. When she was seven, her father would
immobilize her with handcuffs and then proceed to rape her as well as
beat her with a stick. Her wounds came to the attention of the school
authorities, and the father was arrested. Instead of receiving the life
sentence he deserved, his mother bailed him out of jail where he had
been held for several weeks. By the time I saw my patient years lat-
er, her life consisted of a series of brief and stormy relationships with
men, drug abuse, suicide gestures, and all-too-understandable anger
and misanthropy. There was no indication that there had been bipolar
relatives in her background—not even her father, who was a sadistic
psychopath, but not a manic-depressive.

INADEQUATE MOTHERING

Thus far we have focused on the presence of hostile or hurtful par-

enting, especially in the form of sexual molestation, as a forerunner of
BPD psychopathology. There are other BPD patients for whom inad-
equate mothering appears to have played a prominent, at times even
decisive role in the development of their personality disorder. The poor
mothering might come in the form of neglect, active cruelty or hostility,
or some combination.
One borderline patient I worked with 20 years ago was the survivor
of a car-crash in which both her Korean parents were killed. At age four,
she was then raised by an uncle and aunt. The aunt would feed her
own children, but would starve her niece or else do cruel things to her,
like shove chopsticks into the back of her throat. The aunt let her own
children use the bathroom, but made her niece go outdoors and leave
her waste in the yard. Her uncle and male cousin then committed incest
with her when she got a little older. Finally, when in her mid-teens, she
came to the United States to live with families that take in students.
Though she was an A-student at a prestigious university, she struggled
with agoraphobia, bouts of self-cutting, and suicide gestures that at one
point necessitated hospitalization. She was quite an appealing young
woman, but her fear of abandonment and clinginess proved burden-
some to her boyfriends, who eventually left her.
I treated several women with BPD who had grown up in prominent
families of great wealth, where the fathers were indifferent to their chil-
dren while the mothers were basically decent and caring women whose
 CLINCIAL TREATMENT GUIDES FOR BPD 17

husbands commandeered their time to such an extent that they had

very little time for their children. These patients, in effect, had a lov-
ing mother who just wasn’t there. These patients found being alone
intolerable and tended to develop eating disorders (anorexia or buli-
marexia). Several of these effectively “motherless” young women had
sexual relationships with other female students at college, so that the
(now sexualized) closeness served to compensate to a degree for what
had been missing in their original mother-daughter relationship. I have
treated several patients with BPD whose mothers were scarcely avail-
able—whose longing for closeness with a mother expressed itself in
their dreams as having sex with another woman. As one enters puberty,
the emerging sexuality often adds an element of sexual coloration to
an underlying wish for closeness. These women were frightened that
they were becoming lesbians and the exploration of this material was
so fraught that further psychoanalytic work on this issue proved too
uncomfortable. The “cure” was instead to find the right man, marry,
and envelop themselves in the blanket of conventional and, for them,
reassuring, heterosexuality. These patients did succeed in finding suit-
able mates—allowing their mother-longing and homosexual fears to be
given a decent “closed casket” burial.
Some of the patients had mothers who were openly hostile toward
them. One such mother, who was divorced from the father when their
daughter was four, forbade the girl any contact, even by phone, with
the father. I treated this patient when she was hospitalized for a suicide
attempt just after starting college. For a time, she was sexually promis-
cuous, but hostile to the men she would consort with; she was intensely
lonely, felt alienated, and was consumed with envy for people who had
ordinary lives. She did not become reunited with her father until her
late 30s, and she then married an older man with whom she was finally
able to carve out a pleasant and productive life (Stone, 1990). As with
many women with BPD, she chose not to have children, perhaps sens-
ing inchoately that, lacking the usual template for mothering that girls
absorb from having a good mother, becoming a mother herself would
not be a comfortable or rewarding task.

DISCUSSION

Regarding a possible hereditary factor predisposing to BPD, the very

term borderline was used in the early 20th century to designate a condi-
tion that in milder form resembled—that is, was “borderline” to—one
of the two major psychoses, whether schizophrenia or manic-depres-
sion (now bipolar disorder). As mentioned above, there was a tighter
18 STONE

connection, both conceptually and epidemiologically, between schizo-

typal personality and (full-blown) schizophrenia. The connection be-
tween BPD and bipolar disorder seemed weaker. In an earlier article,
for example, McGlashan (1983) noted that the evidence then avail-
able suggested schizotypal personality as a variant of schizophrenia,
whereas any connection between BPD and primary affective disorder
(viz. bipolar disorder) was suggested but not conclusive. Twin stud-
ies by Torgersen in Norway (1984) found that genetic factors appeared
to influence the development of schizotypal personality, but not bor-
derline personality. A decade later, he was even more skeptical about
genetic transmission in BPD (Torgersen, 1994). Contemporary thought,
as outlined by Kavoussi and Siever (1992), acknowledges that there is,
nevertheless, a measure of overlap between the two personality types,
but this is more likely a manifestation of dimensional psychology—as
emphasized in Plomin’s work (2018). Much of the confusion concern-
ing the legitimacy of genetic factors in BPD stems, however, from a
failure to appreciate that the characteristics of schizotypal personality
emphasize cognitive peculiarities (eccentric speech, ideas of reference,
etc.), which are hardly likely to arise in relation to incest, bad parenting,
maternal neglect, or the other disadvantages that show up repeatedly
in the histories of BPD patients. So schizotypal characteristics emerge
as formes frustes (a crude or unfinished form) of the major psychosis;
namely, the predominantly cognitive psychosis of schizophrenia. But
the emotional dysregulation that is the sum and substance of BPD can
indeed arise out of either hereditary predisposition to a mood-oriented
psychosis (manic-depression/bipolar disorder) or the disruptive or vi-
olent or neglectful parental rearing that, as noted earlier, is present in
the great bulk of BPD patients. The exceptions are those few borderline
patients who—as in some of the clinical vignettes above—had warm
and loving parents, and who were not abused, molested, neglected, or
even affected by the death of a parent in their formative years. In these
admittedly uncommon borderline patients, there is nothing left to ac-
count for their psychopathology except genetic influences. So from this
perspective, BPD may be best understood as a mixed condition etiolog-
ically: a disorder of emotional regulation that may arise primarily from
(a) disadvantageous early environment, (b) genetic loading for bipolar
disorder, or (c) a mixture of the two. It should be recalled that a certain
proportion of persons diagnosed in adolescence or their early 20s with
BPD go on to show clear-cut signs of bipolar disorder as they enter
adult life. Among the latter, there is a tendency to remain symptomatic
and burdened as they grow older, in contrast to the larger group of pri-
marily environmentally disadvantaged BPD patients, many of whom,
especially with good treatment, become healthier as they get past 30—
 CLINCIAL TREATMENT GUIDES FOR BPD 19

and live essentially well, achieving remission and even recovery (Stone,
1990; Zanarini et al., 2012).
As for the impact of incest and other forms of abusive or otherwise
disadvantageous parenting (such as neglect or punitiveness), there is
a variety of pathological consequences. Becoming borderline is one of
them—one manifestation of which is a heightened “free-floating anxi-
ety” (Dulz & Schreyer, 1997). Incest may also lead to the development
of insecure attachment, as well as to the characteristics of post-traumat-
ic stress disorder (PTSD)—with its startle responses, nightmares, intru-
sive recollections of original traumatic events, and so forth (Alexander
et al., 1998). In another study, the timing at which incest experiences
occurred played a role in the later severity of symptomatology. McLean
and Gallop (2003), for example, found that the development of BPD
and complex PTSD was more common in women who had experienced
early-onset versus late-onset (viz. post-pubertal) paternal incest.
Erdinç and colleagues (2004) point to the multiple effects associated
with incest: besides BPD and PTSD, one also encounters dissociative
amnesia—the latter characterized by an obliteration from memory of
the traumatic sexual experiences (until eventually restored through
psychotherapy). Another unfortunate consequence of the incest experi-
ence, observed in a number of gynecologic patients, was chronic pelvic
pain, in addition to BPD. Early family dysfunction, including incest,
was noted in a significant proportion of these women (Gross, Doerr,
Caldirola, Guzinski, & Ripley, 1980/1981).
One of the defining attributes of BPD is “inappropriate, intense an-
ger or difficulty controlling anger” (American Psychiatric Association,
2013). Kernberg (1994) has examined the issue from the perspective of
the relationship between inborn (i.e., genetic) predisposition to aggres-
sive behavior versus the (post-natal) effects of severe trauma and psy-
chosocial pathology stemming from adverse early experiences. From
a therapeutic standpoint, he drew attention to management of intense
hatred, linked to aggression, in the transference, when a psychoana-
lytically oriented form of therapy is the primary treatment modality.
It is clear from both the clinical vignettes and the references on incest
cited here that inordinate anger may arise from both pre- and post-
natal influences. Many persons born with a genetic predisposition to
bipolar disorder may show the predominantly manic symptomatology,
a common manifestation of which, along with manic grandiosity, is the
temperamental factor of (extreme) irritability. The latter may surface as
a personality marked by a heightened predisposition to anger. And as
we have noted, a good number of patients with BPD have developed as
borderline via this form of inheritance, even if raised in a non-abusive
(and incest-free) environment. But as also noted, many patients with
20 STONE

BPD, even with no known risk for bipolar disorder, come by their inor-
dinate anger in reaction to incest or to other adverse factors, such as pa-
rental brutality or devastating criticism and humiliation. We have also
drawn attention to the many combined cases of BPD, where the patient
has been burdened by both genetic and environmental disadvantages.
Though most of the related literature stems from studies in the United
States and Europe, a similar situation is described in an article from the
Indian subcontinent (Menon, Chaudhari, Saldanha, Devabhaktuni, &
Bhattacharya, 2016). In their study of 36 BPD patients, almost half (16
or 44%) reported a history of childhood sexual abuse, usually occurring
between the ages of seven and twelve. The abnormalities ascribed to
the abuse were chiefly identity disturbance, recurrent suicidal or self-
harm behaviors, and paranoid/dissociative symptoms. It is worth re-
calling that the intense jealousy noted in certain sexually abused BPD
patients, especially incest victims, is itself a paranoid reaction in which
all subsequent sexual partners are suspect—of infidelity. In the typical
case of father-daughter incest, the daughter comes to realize that her
father was obviously unfaithful to her mother—so, in effect, how can
any man be trusted?
Though incest in BPD patients has gotten considerable attention,
others have drawn attention to the high frequency of adverse parental
factors. Judith Herman and colleagues (1989) mentioned, for example,
how in their studies four out of five (81%) patients with BPD had suf-
fered some form of abuse, including physical abuse (71%), sexual abuse
(68%), and witnessing serious domestic violence (62%). One colleague
in the Herman, Perry, and van der Kolk article explains further that
prolonged and severe trauma early in life often leads to the emotional
dysregulation that is a key feature of BPD—predisposing to self-sooth-
ing behaviors: clinginess and overdependency in relationships, eating
disorders, substance abuse, or the paradoxical self-mutilation—para-
doxical because self-cutting, for example, would be painful for an or-
dinary person, but is acceptable to some borderline patients, since the
controlled and bearable physical pain becomes an antidote to the un-
bearable and global psychological pain (van der Kolk, Hostetler, Herron,
& Fisler, 1994). Some consider traumatic childhood to be the main etio-
logical factor in the development of BPD (Kuritárné, 2005), although
I believe this impression is to an extent sample-dependent. Cultural
and socioeconomic factors enter into the equation, since (as shown by
Russell, 1986) incest and family brutality are more common in certain
cultural backgrounds and socioeconomic conditions and less so in oth-
ers, such that the balance between genetic and environmental factors
is not the same in all samples of BPD patients. More detailed impres-
sions and connections arose out of the large-scale study of 290 BPD
 CLINCIAL TREATMENT GUIDES FOR BPD 21

patients by Zanarini and her colleagues (2002). Sexual abuse, for ex-
ample, tended to occur both in childhood and adolescence on a weekly
basis, usually for a year or more. Sexual penetration and/or use of force
were widespread, occurring in over half the cases. Severity of the abuse
was noted to correlate with symptom severity in all the major aspects
of borderline psychopathology; namely, affect, cognition, impulsivity,
and disturbed interpersonal relationships. Others have been at pains to
remind us that several personality disorders besides BPD are also often
set in motion by sexual and physical abuse, especially paranoid and
antisocial disorders. The marked jealousy in certain women who had
been incest victims is itself a variety of paranoid disorder. Sexual, phys-
ical, and emotional abuse was common in the backgrounds of paranoid
patients of whatever sort (Bierer et al., 2003).
Indeed, cases of pure BPD—with no accompanying personality
disorders—are all but unknown. Almost invariably, BPD will be ac-
companied by one or more comorbid personality disorders, especially
among the so-called dramatic cluster in DSM: histrionic, narcissistic,
and antisocial. But other disorders are also common: paranoid and de-
pendent (Oldham, Skodol, Hyler, Rosnick, & Davies, 1992). In this re-
gard, the only patient I treated in the past 50 years who was the victim
of father-son incest (he had been anally raped repeatedly during his
adolescence) met criteria for BPD (he showed five items: identity dis-
turbance, suicidal behaviors, affective instability, inappropriate anger,
and stress-related paranoid ideation), but also, and more prominently,
for paranoid personality disorder. Adding to his distrust and paranoid
development was his older brother who, out of wanton cruelty, used to
push his hands onto a hot radiator. Though he was a linguistics scholar,
his self-regard was severely impaired, and he felt that I looked down
on him as though I would “rather treat a Rockefeller for nothing” than
treat him for a modest fee. In the beginning, he made violent threats
toward me, but softened when he realized that we had some things in
common; we both spoke German and Japanese and were both aficio-
nados of opera. But he never overcame his distrust of his co-workers
and often felt the police were checking up on him. My work with him
was primarily supportive, in hopes of enhancing his self-esteem. On
one occasion when he was about to throw away his opera ticket be-
cause he didn’t deserve it, I wrote on a prescription pad: “Go to the
damn opera!” And he did. This was in line with the recommendations
of Gunderson and Chu (1993) who advised, when dealing with bor-
derline patients who had been traumatized via early child abuse, that
clinicians endeavor to facilitate a stronger therapeutic alliance through
acknowledgement of the patient’s victimization: this, by enhancing the
patient’s often enfeebled sense of self-worth. The authors also under-
22 STONE

lined the value of reframing the patient’s experience in the here and
now as a consequence of the childhood trauma. In the case of my sexu-
ally and physically brutalized patient, my task was to help him un-
derstand—through sympathy and decency, more than through correct
interpretations—that the human race was not as universally malign as
his past had taught him to expect. In line with the growing emphasis
on early childhood trauma as the primary factor setting in motion the
development of BPD, Saunders and Arnold, writing in the same year
as the Gunderson and Chu article (1993), criticized the inconsistent
findings of the earlier etiological speculations that emphasized sepa-
ration-individuation issues, empathic failures in early childhood, early
losses and separations, and so forth. Instead they remarked how a half
to three-quarters of BPD patients had childhood abuse and trauma in
their histories—which Saunders and Arnold saw as of greater etiologi-
cal importance. These impressions are more in harmony with my own
views, where many of the personality traits seen again and again in
BPD patients can be ascribed in fair measure to incest victimization—
particularly, mistrustfulness, jealousy, seductiveness, hostility, impul-
sivity, defiance, and emotional volatility (Stone, 1989). The critique of
Saunders and Arnold (1993) notwithstanding, we should not overlook
the impact in certain borderline patients of problems relating to ad-
verse mother-child, rather than father-child, interactions.
In a study from Heidelberg and Palermo of 44 adolescent female
hospitalized borderline patients and 47 controls, the three main inde-
pendent predictors of the BPD–related psychopathology were (in that
order) sexual abuse, generally dysfunctional family, and low maternal
care (Infurna et al., 2016). Under the heading of “low maternal care,”
there were several varieties. Some mothers, for example, offered what
was called “affectionless control”—characterized by low care and high
overprotection. This was often associated with subsequent depressive
syndromes. Some mothers, in contrast, showed “neglectful parenting,”
where there was low care and little protection. The authors speculated
that inadequate mothering might magnify the ill effects of other forms
of parental maltreatment (including sexual or physical abuse).
In my own studies, 28% of the female BPD patients had had to deal
with maternal inadequacies. In the largest group (12 patients), the
problem was chiefly maternal hostility. Three of the patients had also
been incest victims. There had been one suicide. The hostility often took
the form of withering criticism and contempt; one of the mothers had
also been physically abusive. Six of the mothers had been neglectful;
sometimes this took the form of grossly preferring the patient’s brother.
Three of the mothers had been warm and consistently caring—but had
been rendered largely unavailable emotionally because their husbands
 CLINCIAL TREATMENT GUIDES FOR BPD 23

resented their attention to the children and commandeered their wives’

attention all to themselves. The fathers insisted on long vacations with-
out the children, and interfered in other ways with any efforts on their
wives’ part to spend more time with the children. All but one of the
patients suffered from depression; half of the 12 with hostile mothers
eventually showed signs of bipolar disorder, including the one woman
who committed suicide. In this entire group, inadequate or disturbed
mother-daughter relationships together constituted an important fac-
tor predisposing to BPD, and occurred as often as the more dramatic
(and probably still more pathogenic) incest factor. But half of the entire
patient group was bipolar, meaning that there was a confluence of ge-
netic and environmental factors in them that underlay their borderline
disorder. The proportion of these factors will presumably vary from
one sample of BPD patients to another, but it is highly unlikely that in
any large sample the patients would all be of the genetic type or else
exclusively all of the adverse parenting type.
In general, the importance of paying attention to both genetic and
environmental factors when evaluating a new patient who appears to
meet criteria for BPD is precisely because BPD is a syndrome—in effect,
a mixture of symptoms (such as anxiety, mood disturbances, etc.) and
personality traits (inordinate anger, paranoid tendencies, impulsivity),
rather than a personality disorder in the strict sense of the term, com-
posed merely of actual traits (as is the case, for example, with depen-
dent and schizoid disorders). Each patient with BPD needs to be seen as
situated along a spectrum—with the primarily genetic-engendered at
one end and the primarily environment-based at the other, and with all
the other combinations in between. This places an emphasis on taking
a detailed family history (including grandparents, aunts, uncles, and
cousins, etc.) to ascertain whether there are relatives with mood dis-
orders or psychotic conditions. With female patients, inquiry about al-
terations in mood and irritability around the time of the menses is also
important—since such disturbances, especially if severe, may point to
possible bipolar vulnerability. If the latter is present, the medication
regime may well require the addition of a mood stabilizer, such as lith-
ium or lamotrigine, since psychotherapy of any sort would not suffice
(as was the case with the suicidal young woman mentioned above who
required lithium and clozapine to restore emotional equilibrium).
Another important consideration at the outset of treatment with bor-
derline patients is the assessment of their cognitive style. Those with
a good reflective capacity and of an introspective turn of mind are apt
to work well with a psychoanalytically based approach (expressive
psychotherapy, transference-focused psychotherapy, or other similar
method). In patients where those capacities are not very prominent,
24 STONE

a cognitive-behavioral approach (dialectic behavioral therapy, schema

therapy, etc.) may prove more effective (Stone, 2017b). Treatment with
borderline patients is generally a lengthy process. As such, what may
have been a suitable treatment approach at the outset may be less suit-
able at a later stage, when a shift to a different modality may prove
more effective. As emphasized by Judd and McGlashan (2003) and
Livesley (2008, 2012), flexibility in treatment methods will be a key ele-
ment in the therapist’s overall approach.

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