BORDERLINE PERSONALITY

DISORDER

A Clinical Guide
SECOND EDITION

John G. Gunderson, M.D.

Professor of Psychiatry at Harvard Medical School
Director of Psychosocial and Personality Research and
Director of the Borderline Personality Disorder Center
McLean Hospital
Belmont, Massachusetts

With
Paul S. Links, M.D., F.R.C.P.C.
Professor of Psychiatry at the University of Toronto, Canada

Washington, DC
London, England
Note: The authors have worked to ensure that all information in this
book is accurate at the time of publication and consistent with general
psychiatric and medical standards, and that information concerning
drug dosages, schedules, and routes of administration is accurate at the
time of publication and consistent with standards set by the U.S. Food
and Drug Administration and the general medical community. As medi-
cal research and practice continue to advance, however, therapeutic stan-
dards may change. Moreover, specific situations may require a specific
therapeutic response not included in this book. For these reasons and
because human and mechanical errors sometimes occur, we recommend
that readers follow the advice of physicians directly involved in their care
or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the
views and opinions of the individual authors and do not necessarily rep-
resent the policies and opinions of APPI or the American Psychiatric As-
sociation.
The authors of this book, John G. Gunderson, M.D., and Paul S. Links,
M.D., F.R.C.P.C., have no competing interests to disclose.
Copyright © 2008 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Gunderson, John G., 1942–
Borderline personality disorder : a clinical guide / John G. Gunderson
with Paul S. Links. — 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-335-8 (alk. paper)
1. Borderline personality disorder. I. Links, Paul S. II. Title.
[DNLM: 1. Borderline Personality Disorder. WM 190 G975ba 2008]
RC569.5.B67G863 2008
616.85'852—dc22
2008005061
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

1 The Borderline Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 1

Origins of the Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Shifts in the Borderline Construct: From Organization to
Syndrome to Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
An Explication of the DSM-IV Criteria . . . . . . . . . . . . . . . . . . 9
A Clinical Synthesis: Intolerance of Aloneness . . . . . . . . . . 18
Misuses of the Borderline Diagnosis . . . . . . . . . . . . . . . . . . . 22
The Behavioral Specialty: Self-Injurious Behavior . . . . . . . . 24
Use of the Diagnosis in Adolescents . . . . . . . . . . . . . . . . . . . 27
How to Explain the Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 27
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

2 Differential Diagnosis: Overlaps, Subtleties, and

Treatment Implications . . . . . . . . . . . . . . . . . . . . . . . . 37
Overall Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
The Changing Construct: From Schizophrenia to
Depression to Posttraumatic Stress Disorder to
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Comorbidity and Differential Diagnosis . . . . . . . . . . . . . . . . 40
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3 Overview of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Historical Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Generic Therapeutic Processes and the Functions
They Serve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Multiple Modalities and Step-Down Services:
An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Sociotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Establishing Goals: The Expectable
Sequence of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Changes Within Four Spheres . . . . . . . . . . . . . . . . . . . . . . . . 77
The Initial Structuring of Treatment . . . . . . . . . . . . . . . . . . 80
Types and Sequence of Therapeutic Alliance . . . . . . . . . . . . 82
Countertransference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

4 Case Management: The Primary Clinician . . . . . . . . 89

Qualifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Liability Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Relationship Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Managing Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Responding to Recurrent Suicidality: The Principle of
False Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Implementing Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Boundaries, Violations, and Setting Limits . . . . . . . . . . . . . 106
Splits, Splitting, and the Virtues of Split Treatments . . . . . 107
Giving, Receiving, and Participating in Supervision . . . . . . 110
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

5 Levels of Care: Indications, Structure, Staffing . . . . 113

Selecting or Changing a Level of Care . . . . . . . . . . . . . . . . 114
Level IV: Hospital Treatment—Makes Therapy Possible . . . 115
Level III: Residential/Partial Hospital Care/
Day Treatment—Basic Socialization . . . . . . . . . . . . . . . . 122
Level II: Intensive Outpatient Care—
Behavioral Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Level I: Outpatient Care—Interpersonal Growth . . . . . . . . 133
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
6 Pharmacotherapy: Clinical Practices . . . . . . . . . . . 139
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Overall Role of Medications . . . . . . . . . . . . . . . . . . . . . . . . . 140
Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
The Prescribing Psychiatrist’s Role . . . . . . . . . . . . . . . . . . . 143
Symptom Chasing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Attitudes, Meanings, and Attributions . . . . . . . . . . . . . . . . . 148
Transference-Countertransference Issues . . . . . . . . . . . . . . 149
Contraindications and Discontinuance . . . . . . . . . . . . . . . . 151
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

7 Pharmacotherapy: Selection of Medications . . . . . 157

Pharmacotherapy Models . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
The Symptom-Targeted Model . . . . . . . . . . . . . . . . . . . . . . 158
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

8 Family Interventions and Therapies . . . . . . . . . . . . . 177

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Therapists and Countertransferences . . . . . . . . . . . . . . . . . 180
Getting Started: Overcoming Resistance . . . . . . . . . . . . . . . 181
Phase 1: Initial Family Meetings . . . . . . . . . . . . . . . . . . . . . . 183
Phase 2: Establishing an Alliance . . . . . . . . . . . . . . . . . . . . . 187
Phase 3: Psychoeducational Family Therapy . . . . . . . . . . . . 189
Phase 4: Psychodynamic Family Therapy . . . . . . . . . . . . . . 196
Marital or Couples Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 197
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

9 Group Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Engaging Patients and the Primary Clinician’s Role . . . . . 208
Skills Training Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Psychodynamic Group Therapies . . . . . . . . . . . . . . . . . . . . 214
Group Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Common Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
10 Individual Psychotherapies: Getting Started . . . . . . 225
Introduction: Prerequisites . . . . . . . . . . . . . . . . . . . . . . . . . 225
Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Structuring the Therapeutic Frame
(External Boundaries) . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Therapists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Generic Qualities of Effective Psychotherapies . . . . . . . . . 247
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

11 Cognitive-Behavioral Therapies: Dialectical

Behavior Therapy and Cognitive Therapies . . . . . . 253
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Basic Operant Conditioning Applications for All
Treatment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Dialectical Behavior Therapy . . . . . . . . . . . . . . . . . . . . . . . . 256
Cognitive Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274

12 Psychodynamic Psychotherapies . . . . . . . . . . . . . . 279

Pre-Empirical Developments . . . . . . . . . . . . . . . . . . . . . . . . 280
Outcome Studies: Nonrandomized Trials . . . . . . . . . . . . . . 282
Transference-Focused Psychotherapy . . . . . . . . . . . . . . . . . 286
Overview of Change Processes . . . . . . . . . . . . . . . . . . . . . . . 289
Phase 2: A Relational Alliance . . . . . . . . . . . . . . . . . . . . . . . 291
Phase 3: Positive Dependency . . . . . . . . . . . . . . . . . . . . . . . 298
Phase 4: Secure Attachment, the Working Alliance,
and Consolidation of Self . . . . . . . . . . . . . . . . . . . . . . . . 304
Impasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

13 Future Considerations . . . . . . . . . . . . . . . . . . . . . . . . 315

Treatment Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Diagnostic Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Public Awareness and Advocacy . . . . . . . . . . . . . . . . . . . . . . 321
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Appendix Psychoeducational Resources:
Printed Materials, Videos, Films, and Web Sites . . . 329
Printed Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Videos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

List of Sidebars
1–1: Where Were the Borderline Patients Before
the Diagnosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1–2: The Subjective Experience of Being Borderline . . . . . 13
1–3: Borderline Personality as an Iatrogenic Disorder . . . . 15
1–4: British Developmentalists: From Winnicott to
Bowlby to Fonagy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1–5: “Wisdom Is Never Calling a Patient Borderline” . . . . 23
1–6: Cutting: Social Contagion or
Psychopathology? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2–1: Was Vincent van Gogh Borderline? . . . . . . . . . . . . . 46
2–2: Is Martha Stewart Borderline? . . . . . . . . . . . . . . . . . . . 53
3–1: Should Consumers Receive Progress Reports? . . . . . 74
3–2: Myths About Alliance With Borderline Patients . . . . . 83
4–1: Guidelines to Avoid Liability . . . . . . . . . . . . . . . . . . . . 93
4–2: Is Contracting for Safety Safe? . . . . . . . . . . . . . . . . . . 99
5–1: Can Long-Term Hospitalization Be Desirable
for BPD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5–2: How Psychotherapeutic Technique Relates to
Level of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
5–3: Vocational Counseling: Should a Borderline
Patient Return to School, Pursue a Career, or
Become a Caregiver? . . . . . . . . . . . . . . . . . . . . . . . . 123
5–4: Empirical Support for a Specialized
“Mentalization-Based” Day Hospital . . . . . . . . . . . . 128
6–1: Listening to Prozac: Can Selective
Serotonin Reuptake Inhibitors Cure BPD? . . . . . . . . 141
6–2: Liability Hazards of Split Treatment . . . . . . . . . . . . . . 147
8–1: “You Can’t Talk to My Parents” . . . . . . . . . . . . . . . . . 182
8–2: Families of Married Borderline Patients . . . . . . . . . . 184
8–3: Finessing the Guilt Issue . . . . . . . . . . . . . . . . . . . . . . . 186
8–4: “Good Cop/Bad Cop”: A Parental Problem . . . . . 191
8–5: Makes Sense, But Does it Work?
Preliminary Findings of the Psychoeducational
Multiple-Family Group . . . . . . . . . . . . . . . . . . . . . . . . 195
9–1: Research on Interpersonal Group Therapy
With BPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
10–1: Quality Assurance: Should Therapists Be
Credentialed to Treat BPD? . . . . . . . . . . . . . . . . . . . 240
10–2: Listening to Kernberg or Linehan: Can Charisma
Cure BPD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
11–1: Schema-Focused Therapy: Does It Work? . . . . . . . 269
12–1: Kernberg Versus Kohut/Adler: The Debate of
the 1970s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
12–2: Kernberg Versus Linehan: The Debate of
the 1990s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
12–3: Transitional Objects: From Concept to
Phenomenon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
12–4: Is Regression Therapeutic? The Two Margarets . . . . 302
13–1: Were a Famous Borderline Person
to Go Public… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
ABOUT THE AUTHORS

John G. Gunderson, M.D., is Professor of Psychiatry at Harvard Medical

School, Boston, Massachusetts. At McLean Hospital in Belmont, Massa-
chusetts, he serves as Director of Psychosocial and Personality Research
and of the Borderline Personality Disorder Center.
Dr. Gunderson has been integrally involved in the diagnosis and treat-
ment of borderline personality disorder since 1969. His studies helped to
define the diagnosis of borderline personality disorder and establish an
empirical standard for evaluating treatment of this disorder.

Paul S. Links, M.D., F.R.C.P.C., is Professor of Psychiatry at the Univer-

sity of Toronto, Canada. At St. Michael’s Hospital, he is serving his third
term as the Arthur Sommer Rotenberg Chair in Suicide Studies.

xi
INTRODUCTION

THIS BOOK IS A SEQUEL to Borderline Personality Disorder: A Clinical

Guide, published in 2001, which was a sequel to Borderline Personality Dis-
order, published in 1984. These books have summarized what was
known—or believed—about treating borderline personality disorder
(BPD) at the time of their publication. This revision of the 2001 book up-
dates the rapidly expanding treatment literature. Clinical perspectives,
concepts, and modalities continue to become more sophisticated, de-
tailed, and empirically buttressed. A great deal is currently known about
what to do and, just as important, what not to do to treat BPD effectively.
After only a 7-year interval, a significant revision was needed to accom-
modate the mushrooming of information, expertise, and specialization.
This book is meant to cover comprehensively all the recognized thera-
pies for BPD. It details long-term multimodal treatment, with an apprecia-
tion that no one modality is by itself sufficient. I attempt to emphasize
advances from empirical research and to synthesize them with what is feasi-
ble and with what derives from clinical experience. Above all, this book is
meant to be useful and practical, primarily for clinicians, but also potentially
for trainees, patients’ families, and health care administrators. Although no
treatment is excluded from consideration because of its cost, all treatments
are considered with issues of cost-effectiveness and feasibility in mind.
The first chapter covers the issue of the diagnosis itself: what the diag-
nosis means and the biases that affect its use. Special attention is given to
the borderline patients’ behavioral specialty (i.e., their self-destructive-
ness) and to the use of this diagnosis in adolescents. Perhaps the most im-
portant message for clinicians is that we do these patients (and their
families) a favor by identifying the diagnosis and educating them about it.
Patients and families deserve to know what is known, and, as often as not,
the success of treatments rests on their being included as responsible allies.
Chapter 2 describes BPD’s most common differential diagnostic is-
sues. These have shifted from schizophrenia to depression to posttrau-
matic stress disorder to the current controversy about the interface with
bipolar disorder. The last issue is now given more attention.

xiii
xiv ❘ BORDERLINE PERSONALITY DISORDER: A CLINICAL GUIDE

Three theories guide most clinicians—biological, cognitive-behav-

ioral, and psychodynamic. My psychodynamic background inevitably an-
chors much of this book, but the theory most central to this book’s goals
is a theory about therapies found in Chapter 3. Chapter 3 offers an em-
pirically and clinically anchored theory on the sequencing of goals (i.e.,
targets for intervention), on processes of change, and on the modalities
that are best suited for a patient’s changing needs. The chapter under-
scores the feasibility and value of establishing initial short-term goals. In
this chapter, I also describe the basic role of psychoeducation for patients
and families—both as a way to establish an alliance with longer-term goals
and as a therapeutic intervention in its own right. Psychoeducation su-
perimposes a logic on treatment planning, and it anticipates the se-
quence of the chapters that compose the rest of the book.
After Chapter 3, the book proceeds to chapters concerning the imple-
mentation of overall treatment plans (Chapters 4 and 5). These chapters
emphasize the need for someone to develop the plan, establish an appro-
priate level of care, and include rehabilitative services that address the
borderline patients’ typically severe impairments in social functioning.
Chapters 6 through 12 describe the specific modalities in a sequence con-
sistent with the severity of the borderline patient’s mental state and with
the length of time needed to meet the primary goals of each modality.
Chapter 4 outlines the primary clinician’s responsibilities. In an era
when managed care hovers in the background of treatment authoriza-
tion, and in which care of borderline patients moves across multiple set-
tings, it is easy to ignore the central requirement of having some one
clinician be identified to all, including the patient, as being in charge—
the primary clinician. This chapter introduces the thesis that rather than
being problematic, split treatments that emerge from the current multi-
modal, multitreater environment are treatment enhancing. This book re-
peatedly points out how a treatment having two or more components not
only adds breadth to the treatment goals but also offers a structure that
safeguards treatment against the borderline patients’ enactment of their
intrapsychic splits.
Chapter 5 concerns four levels of care. Here empirical evidence is in-
troduced about the potential value of the two most intensive levels: hospital
care (level IV) and residential or partial hospital (level III). The four levels
are not seen here as competitive but as having different goals, durations
(this was intended 7 years ago), structures, and staffing. Of most interest
may be the endorsement given to a newer level of care, intensive outpatient
programs. Intensive outpatient programs represent a level of care that, al-
though not widely available, may be more effective and certainly more cost-
beneficial than relying on hospital or partial hospital services.
Introduction ❘ xv

Reflecting the fact that medications have quietly become the single
most widely and uniformly used treatment for BPD, two chapters (6 and
7) are devoted to psychopharmacology. Chapter 6 offers an extensive ac-
count of the seemingly irrational in vivo complexities surrounding pre-
scribing medications and evaluating their effectiveness. In contrast,
Chapter 7 offers a rational algorithm to guide selection of medications
that should usefully inform prescribing physicians.
Chapter 8 encourages clinicians to involve families far more than has
been customary. I describe how clinicians can use consumer-friendly
psychoeducational interventions. Note that many interventions, albeit
brief and not called therapies, may be very valuable. Furthermore, use of
traditional dynamic family therapies is reserved for only selected cases
and then only in a late stage of treatment. For most families, the primary
treatments are parental coaching and assisted problem solving. Prelimi-
nary data that show the value of such coaching and problem solving are
offered.
Chapter 9 underscores the role that interpersonal groups should play
in the first year or so of most borderline patients’ treatment. This type of
treatment is readily exportable and nicely complements the functions
served by individual therapies or psychopharmacology by addressing the
interpersonal impairment that is central to most borderline patients’ dis-
order. The available empirical evidence underscores the need for more
use of and more research on interpersonal groups.
In Chapter 10, I argue that initiating individual psychotherapy should
be done selectively, taking into account the motivation, the aptitude, and
the social supports required of both patients and therapists. Otherwise
skilled cognitive-behavioral or dynamically oriented therapists still need
special training and experience, and perhaps special personality traits, to
do such therapies well. Chapter 10 also outlines some of the general over-
lapping characteristics of all effective psychotherapies.
Although cognitive-behavioral principles have always been needed
for adequate treatment of BPD, Chapter 11 recognizes that specific types
of cognitive-behavioral treatments have now become the cornerstone for
much modern theory and practice. Indeed, dialectical behavior therapy
(DBT) has rapidly become the most BPD-specific and empirically sub-
stantiated treatment for BPD. Unquestionably, DBT was the major ad-
vance in therapeutics of the 1990s. Chapter 11 tries both to acquaint the
uninitiated with DBT and to place it in some perspective. Other notable
developments cited in Chapter 11 include the recent addition of a prom-
ising second empirically validated cognitive-behavioral treatment,
schema-focused psychotherapy, and evidence for the potential for short-
term cognitive-behavioral therapies to be effective for discrete goals.
xvi ❘ BORDERLINE PERSONALITY DISORDER: A CLINICAL GUIDE

Chapter 12 is devoted to psychodynamic (i.e., psychoanalytic) psy-

chotherapy, the modality that for several decades was considered the
treatment of choice for BPD. Chapter 12 highlights the long-needed
emergence of empirical support for Kernberg’s transference-focused
form of therapy. It also delineates the phases of psychotherapeutic
progress and change over a period of 4 or more years. Both the corrective
power of the relationship and the growth made possible by learning (i.e.,
insights) are described. The case is made that progress should be ongo-
ing, and its absence should be cause for review and consultation. This op-
timistic message is set against the need for a protracted multiyear process.
Chapter 13 begins by noting that the borderline diagnosis has
achieved a place in the consciousness of the mental health world, but it is
only beginning to establish a place in the public consciousness. The de-
velopment and influence of the Borderline Personality Disorder Re-
search Foundation, the explicit recognition of a need for more research
on BPD by the National Institute of Mental Health, the rise of family ad-
vocacy groups, and the adoption of BPD as a brain disease by the National
Alliance on Mental Illness dramatically signal that this expansion is un-
der way. Chapter 13 also introduces how the rise in neurobiological re-
search is likely to greatly transform our understanding of borderline
patients.
The remarkable advancements in treatment for BPD described and
celebrated in this book can be expected to continue. The current diver-
sity of theory and research creates a healthy, vibrant vehicle for continued
growth.
Borderline patients require an array of clinical services, any of which
can be harmful or helpful. But to treat this disorder effectively requires
clinicians with specialized knowledge and training. When such condi-
tions are present, beneficial changes occur that greatly reduce patients’
dysphoric mental states and enhance social functioning. Effective treat-
ment results in a concurrent reduction in the burden on borderline pa-
tients’ significant others, an improved morale by treaters, and a decrease
in the otherwise enormous public health costs.
Chapter 1

THE BORDERLINE DIAGNOSIS

THE BORDERLINE PERSONALITY DISORDER (BPD) diagnosis en-

tered the American Psychiatric Association’s DSM-III in 1980 (American
Psychiatric Association 1980) and 12 years later, in 1992, was adapted for
the World Health Organization’s ICD-10 (World Health Organization
1992). The growth in the recognition and use of this diagnosis during the
period from 1975 to 1990 has been remarkable. It is easily the most widely
and commonly used diagnosis for personality disorders in modern clinical
practice (Loranger 1990; Loranger et a1. 1997). Individuals with BPD con-
stitute about 2%–3% of the general population (Swartz et al. 1990; Zim-
merman and Coryell 1989), about 25% of all inpatients, and about 15% of
all outpatients (Koenigsberg et al. 1985; Widiger and Weissman 1991).

Origins of the Diagnosis

The origins of the borderline diagnosis, illustrated in Figure 1–1, are usu-
ally traced to the clinical observations of Adolph Stern (1938), a psycho-
analyst in office practice, who recognized that a subgroup of his patients
disregarded the usual boundaries of psychotherapy and did not fit into the
existing classification system, a system concerned primarily with dividing
psychoses from neuroses. A scholarly review of the work preceding Stern’s
can be found in Mack (1975). The patient group became somewhat more
widely recognized in the early 1950s as a result of several influential papers
by Robert Knight (1953, 1954). He expanded the descriptor borderline
from relating to only the border with neurosis to being equally relevant to
the border with psychosis. Like Stern, he began by decrying the “wastebas-
ket” diagnostic status for such patients. However, he added that failure to
identify the unique needs of these patients was responsible for the trou-
bling disagreements between staff members on inpatient units; he further
stated that this failure led clinicians to ignore providing the structure such

1
2 ❘ BORDERLINE PERSONALITY DISORDER: A CLINICAL GUIDE

FIGURE 1–1. Development of the borderline construct, I.

BPD= borderline personality disorder; BPO= borderline personality organiza-
tion; BSz= borderline schizophrenia; STPD=schizotypal personality disorder.

patients needed to avoid regressing. After Knight, the term borderline to

denote troublesome patients who were neither psychotic nor neurotic
retained some currency but primarily within the community of psychoan-
alysts who worked in hospital settings (Sidebar 1–1).

Sidebar 1–1: Where Were the Borderline Patients

Before the Diagnosis?
A review of medical records from Danish and British psychi-
atric institutions before the diagnosis was used showed that
borderline patients existed (Gunderson et al. 1983; Kroll et
al. 1982). Although Freud himself used the term borderline
only to differentiate delinquent acting-out adolescents
from those with neuroses (Aichhorn 1925/1945, Introduc-
tion), years later Wolberg (1973) rediagnosed one of
Freud’s most famous patients, the “Wolf Man,” as being
borderline. Certainly, before the diagnosis, clinicians (Aich-
horn 1925/1945; Alexander 1930; W. Reich 1949) described
impulse-driven disorders presaging what was to become
the BPD diagnosis. Therefore, there is every reason to be-
lieve that borderline patients were present in clinical set-
tings long before the diagnosis.
Still, it is possible that what was formerly rare is now far
more common. Grinker et al. (1968) suggested that bor-
The Borderline Diagnosis ❘ 3

derline psychopathology is a by-product of social changes

during the twentieth century. The earlier burdens of man-
ual labor and the earlier restrictions of travel, communica-
tion, and leisure time may have offered the structure,
survival activities, and monitors that silently kept such psy-
chopathology in check. Millon (1987) developed a thesis
(subsequently elaborated by Paris [1992]) about sociocul-
tural causes for BPD that, if taken to its extreme, is consis-
tent with the possibility that BPD would have been far less
common in other eras. At present, this thesis can be tested
only by epidemiological work showing whether the inci-
dence and prevalence of BPD vary between cultures and
their levels of modernity.

Use of the term borderline for atypical, clinically troubling cases stag-
gered along in the periphery of psychiatric thinking without notable
progress until developments in the late 1960s. At this point, the conflu-
ence of three independent investigations forced the questions about a
borderline consciousness.
The first of these investigations came from Otto Kernberg (1967).
Even as a relatively young man, Kernberg authoritatively added to the psy-
choanalytic perspective of the borderline construct. He defined borderline
personality organization as one of three forms of personality organization, to
be differentiated from sicker patients, who had psychotic personality organi-
zation, and healthier patients, who had neurotic personality organization (Fig-
ure 1–2). Borderline personality organization was characterized by failed
or weak identity formation, primitive defenses (namely, splitting and pro-
jective identification), and reality testing that transiently lapsed under
stress. Kernberg’s scheme was a conceptual advance within the psycho-
analytic community by virtue of integrating object relations with ego
psychology and the instincts and by virtue of giving a rationale and orga-
nization to a basic classification system. However, the effect of his scheme
within the larger mental health community derived more from the opti-
mistic therapeutic mandates that he gained from his way of understand-
ing these patients than from the concept itself (see Kernberg 1968, 1975).
The second seminal contribution was provided by Roy Grinker et al.
(1968), a senior and respected statesman within American psychiatry. Ar-
mored with a brief personal analysis by Freud himself, Grinker had be-
come chairman of psychiatry at The University of Chicago and editor of
the Archives of General Psychiatry. As one of the early champions of the
need for empirical research, and having already made major contribu-
tions to studies of depression and posttraumatic stress disorder (PTSD),
Grinker undertook the first empirical study of borderline patients. With