Download PDF Treatment Of Borderline Personality Disorder A Guide To Evidence Based Practice by Joel Paris

Sinopsis

A historical perspective helps in understanding the problems of diagnosing BPD. Adolf Stern (1938), the psychoanalyst who first described borderline personality, observed that these patients became worse, not better, in therapy. He suggested this group was unsuitable for analytic treatment because their pathology lay on a “borderline” between neurosis and psychosis. Stern documented their clinical features (“psychic bleeding,” inordinate hypersensitivity, difficulties in both reality testing and relationships), and his description is as relevant today as it was 70 years ago.

However, following Stern’s article, there was only sporadic interest in borderline pathology over the next 30 years. Robert Knight (1953) published a study that added little to what Stern had said and had little impact beyond the psychoanalytic community. Three psychiatrists were responsible for reviving and popularizing the concept of BPD. The first was Otto Kernberg (1970), a psychoana- lyst who first worked at the Menninger Clinic and then at Cornell University. Kernberg proposed that character pathology (or what we now call personality disorder) has three levels: one milder (close to “neurosis”), one moderate, and one severe (i.e., borderline). However, there were two problems with his concept of “borderline personality organization” (BPO). First, it was entirely psychoanalytical in that it was defined on the basis of theories about mental mechanisms rather than on observable behaviors. Second, BPO defined a very broad group of patients with personality disorder as “borderline.”

The second pioneer was Roy Grinker (Grinker, Werble, & Dyre, 1968), working at Michael Reese Hospital in Chicago. Grinker pub- lished the first empirical study of borderline patients, which gave more weight to clinical observation than to psychodynamic speculation and subgrouped patients based on observable symptoms. Grinker’s group also conducted the first systematic follow-up studies of pa- tients with BPD (see Chapter 6). The third, and most influential, pioneer was John Gunderson of McLean Hospital and Harvard Medical School. Gunderson and Making the Diagnosis 5 Singer’s (1975) article in the American Journal of Psychiatry was a turning point for the acceptance of BPD. It showed that this form of pathology could be operationalized with behavioral criteria and that a semistructured interview yielded a reliable diagnosis. I have vivid memories of reading this report. Up to that point, under the influence of my teachers, I had rejected the validity of BPD. The concept seemed all too vague and wooly, and I actually refused to let residents make the diagnosis. However, Gunderson and Singer convinced me, and many others, that the construct was valid. The work of these pioneers influenced the definition of BPD adopted by the Diagnostic and Statistical Manual of Mental Disorders (third edition [DSM-III]; American Psychiatric Association, 1980) 5 years later. The BPD diagnosis was included in DSM, and personality disorders as a whole were given a separate axis. As a re- sult, research took off. In 1987, the International Society for the Study of Personality Disorders (ISSPD) was founded and has met every 2 years ever since. (ISSPD also publishes the Journal of Personal- ity Disorders, now 20 years old.) Because BPD is the most important clinical problem described on Axis II, most personality disorder re- search has focused on this category.

However, there continues to be controversy about the best way to classify the pathology that BPD describes. I discuss three ways to do so. The first is the DSM system (American Psychiatric Associa- tion, 1980, 1987, 1994, 2000), which lists nine criteria, of which five must be present to make a diagnosis. The second is based on four do- mains of pathology, each of which can be scored on a scale. The third is a dimensional approach, in which BPD (as well as all other personality disorders) are described by scores on measures of their underlying traits. 

Content

1. Making the Diagnosis
2. The Boundaries of BPD
3. Personality and Development
4. Risk Factors
5. A General Model
6. Outcome
7. Pharmacotherapy
8. Psychotherapy
9. Guidelines for Management
10. Therapeutic Interventions
11. Problems in Therapy
12. Suicidality and Hospitalization
13. Research Directions

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