Presented By: RICHARD J.KOSCIEJEW
The term ‘borderline state’ has achieved almost no official status in psychiatric nomenclature, and conveys no diagnostic illumination of a case other than the implication that the patient is quite sick but not sincerely a psychotic person. In contrast to neurotics, psychotics seek a solution to their emotional and instinctual conflicts in a regressive escape which involves not only instinctual regression but a severe regressive process in the whole personality organization.
It seems, by admission,, that the central element of this attempt to analyse the descriptive, structural, and genetic-dynamic aspects of ‘borderline personality’ organization, with a special consideration of the characteristic pathology of object relations, draws on the work of many authors with different theoretical positions and with different the therapeutic approaches.
The original goal is having to achieve a definitive induction to accept the psychiatric entity frequently referred to as ‘borderline’. This term in itself has many historical and contemporary meaning. Although attempts have been made by a number of individual therapists to allocate the diagnosis to a specific syndrome, in general it has been used as a depository for clinical uncertainty. Even this usage is not specific because the same uncertainty existing in many clinic’s is hidden by the use of at least a dozen terms, ranging from undifferentiated schizophrenia to anhedonism and character neurosis. These special terms seem to designate commonalities of visible symptoms rather than patterns of functions or dysfunctions.
The diagnosis of borderline has been in use for several decades, or even longer, without clear definition. The term has both technical and general implications which are difficult to separate Our attempt to define what it denotes as a clinical psychiatric syndrome is confusing to those who literally expect the definition to include what bordered on what. We have given much consideration to developing a new diagnostic appellation, which is difficult after the long usage of the old, even though it is semantically unclear. Such that we wanted to use a new word for the syndrome and other terms for the subcategories, but we have nor succeeded in our afforded efforts. This may be accomplished by others who, in their presence awaiting to the future,
Our primary goal, then, is to determine whether a borderline syndrome exists and if so what are its effective characteristics. Yet, to remove the covering from determinant qualities, if subcategories could be delineated and to define them if possible. Thus, the goal at the onset, is to answer the 5question, ‘What is the borderline?’
We begin our investigation in an extent of time set off or typified by someone or something, a periodical intermittence of occurring or appearing in an interrupted sequence such an era as placed throughout the day. As when clinical diagnoses and classifications are derogated, diagnostic skills atrophying and the life-history of psychiatric entities, as not to concern or consider toward an irresolvable incertitude. These tendencies are self-perpetrating because students are being taught to focus, sometimes to their exclusion, on the internal dynamics of the individualization of the patient.
Our designated position as set along the overview, that if an extensive broadened range in scope or application are found extensively wide-ranging or the encompassing amounts of professional literatures, even though selective, disclosed that no systematic study of the borderline has ever been made. The same deficiency applies to other diagnostic terms, serving the purpose of labelling ill-defined syndromes. The bulk of such publications are based on one or a few patients for whom treatment represents the only methodological form of observation, and as such, are couched in the form of psychoanalytic interpretation.. The raw data are deprivingly low, metapsychological’ theory is directly applied and concluded by inferential meaning, rather than definitions of processes. These are carried through the literature as ‘finding’ monotonously confirmed in continuity.
Irrespective of these criticisms which are more generalized than are specific and applicable to a whole specialty, ‘dynamic’ studies disclose patterns that can be translate into hypotheses. That the positive contributions suggest that the borderline is a specific infinity with significant considerations as given to serious thought and finding clarity within the degree of internal consistency and stability, and not a regression as a response to internal or external conditions of stress. It represents a syndrome characteristic of arrested development of ego-functions. None the less, clinicians recognized that the borderline syndrome is a confusing combination of psychotic, neurotic and character disturbances with many normative or healthy elements. Although these symptoms are unstable, the syndrome itself as a process is recognizably stable;, giving rise to the peculiar term ‘stable instability’.
A conclusion can be met, in spite of the value of studies in the internal dynamics of borderline patients and the usefulness of our previous investigations which classified depressions into syndromes or categories on the basis of symptoms, neither was it useful for the study of the borderline. Instead, the decided notations to studying the ego-functions of borderline patients, in so far as they are exposed by ongoing behaviours thereby revealing what were normal healthy or adaptive functions, and what were unhealthy nonadaptive functions. Utilizing a framework of ego-psychology based on psychoanalytic theory promised a better understanding of the syndrome and its subcategories.
The investigatory design is derived, therefore, from a different approach: Instead of using the data of dyadic introspection from a dialogue of discoursing the various forms of psychotherapy or tapping historical or anamnestic data, having to describe observational behaviours, in that the essence so observed and described behaviours and then, rated traits extracted from an ego-psychology framework. This extraction require the redefinition of ego-functions into behavioural variables as exactly as possible and the development of quantitative coding system sufficiently clear and practices so that rater-reliability could be achieved.
Of these assumptions can be summarized as follows:
1. Behaviour can be observed, described and quantified.
2. Behaviour assessed in terms of ego-functions is an index of mentation that the psychotherapist does not typically observe; hence the study of such behaviour adds to the therapist’s store of knowledge of the patient’s assets and liabilities and capacities for adaption.
3. Behavioural evidence have validity in terms of estimating the quality and quantity of internal psychological functions.
4. A large enough time-sample of the behaviour of an individual patient is an adequate index of his ego-functions.
5. A finer analysis of ego-functions in a large enough sample of patients designated by a specific diagnostic term can result in a sharper definition of that specific syndrome.
The ‘borderline’ personality disorders are examined from the descriptive, structural, and genetic-dynamic viewpoints . It is suggested that they have in common (1) symptomatic constellations, such as diffuse anxiety, special forms of polysymptomatic neuroses, and ‘prepsychiotic’ and ‘lower level’ character pathology; (2) certain defensive constellations of the ego, namely, a combination of nonspecific manifestations of ego weakness and a shift toward primary-process thinking on the one hand, and specific primitive defence mechanisms (splitting, primitive idealization, early forms of projection, denial, omnipotence), on the other; (3) a particular pathology of internalized object relations; and (4) characteristic instinctual vicissitudes, namely, a particular pathological condensation of pregenital and genital aims under the overriding influence of pregenital aggressive needs. These various aspects of borderline personality organization and their mutual relationships are a common outcome.
The major finding is that the borderline rubric encompasses a heterogeneous group of psychopathathologic conditions lying predominantly on the border of affective, anxiety, and somantization-antisocial disorders, and, to a minimal extent that of schizophrenic and organic disorders.
Imparting information as instructive didactic properties, the accorded data that favours a freely appointed instrumentality or influence whose notion that borderline disorders are located predominantly on the border of affective rather than schizophrenic psychoses. The relationship to affective disorder is also supported by high rates of familial affective disorder, especially bipolar illness, and those for pharmacologic hypomania. And also finding a lowered threshold for pharmacologic hypomania in cyclothymic and dysthymic disorders, in saying that a common neuropharmacologic substrate for subaffective and borderline disorders. Hence, their diagnosis is best described as borderline manic-depressive psychosis. Even, suggesting that the entire cohort of borderlines suffers from intense affective arousal. This is not surprising in that of the criteria for borderline personality are affectively loaded, in brief, the clinical data on the close link between borderline and affective conditions support the findings that have emerged from the application of neuroendocrine and sleep electroencelphalographic techniques to borderlines.
This, however, conforms to what in the British literature is described as atypical depression or phobic-anxiety-depersonalization syndrome. Intermittent depression occurs in the context of a chronically anxious multiphobic, usually agoraphobic, illness with spontaneous panic attacks characterized by fears of cardiac catastrophe or total mental collapse and associated helplessness and dependency. The highly idiosyncratic manner in which depersonalization and derealization (as part of a panic attack) are experienced, coupled with strong histrionic or obsessional elements, may stimulate bizarre but sort-lived reactive or schizophreniform psychotic episodes. Work by Klein suggests that some of these patients may represent affective variants with history of childhood school phobia, dependent and histrionic features in adulthood, and positive response to imipramine or monoamine oxidase inhjibitors.
This apparency appears to lie on a schizophrenia spectrum as identified in the Danish Adoption studies, for which this modest affinity to schizophrenia is evidenced by clinical schizotypal features with familial background for schizophrenia, and progression to ‘soft’ schizophrenic illnesses (schizophreniform and ‘pseudoneurotic’) and even to process schizophrenia, such that additional sourcing of these diagnoses, has met the criteria for schizophrenia, suggesting that many of the schizotypal features defined, in that they may be nonspecific accompaniments of chronic psychiatric or affective disorders, and that they have diagnostic value in suggesting a subschizophrenic disorder only when they occur in the absence of validated psychiatric disorders.
Even so, this personality subgroup consists of a spectrum of histrionic and sociopathic individuals who have parents with similar or related disorders, who have sustained the tempestuous developmental vicissitudes of unstable parental marriages, and who complain of lifelong intermittent dysphoria. Brief dysphoric psychotic episodes are often precipitated by substance abuse, but may also result from other organic factors.
Other data suggests that schizophreniform episodes are the exception in borderline patients. Grandiose or irritable forms of hypomania - which are sometimes mobilized by antidepressant treatment - as well as depressive delusions are more common. Drug-induced psychoses (i.e., secondary to ethanol, sedative-hypnotic, psychedelic and stimulant abuse, or withdrawal states) represent another plausible explanation for micropsychotic episodes. Finally, depersonalization, derealization and brief reactive psychoses, which are not uncommon in panic, sociopathic and somatization disorders, could easily simulate schizophreniform symptomatology.
Borderline patients appear to suffer from early breaks in attachment bonds largely because of assortative parental psychopathology. In this respect they seem intermediate between nonaffective personality disorder and unipolar affective controls. There is some evidence that among the affective disorders, history of assortative parental psychopathology is most common in bipolar II disorder, such findings strengthen the link between borderline and atypical bipolar disorder. More importantly, our findings suggest that borderline probands are at a double disadvantage; such that they may inherit the illness of one or both parents, and may develop exquisite vulnerability to adult object loss as a result of the tempestuous early home environment. It is also likely that when one parent has affective disorders - affective and characterological. Another possible source of characterological pathology in ‘borderline’ disorders like cyclothymia or bipolar-II is in the hindrance to optimal ego maturation due to the adolescent borderline personality disturbances, generally followed affective episodes. Thymoleptic therapy or long-term lithium stabilization can bring many such patients to a level of ego stability that had not been achieved in years of psychotherapy and nonspecific pharmacotherapy, however, this outcome is not universal, suggesting that maladaptive personality patterns may become irreversible after many years of inadequately treated affective disorders. The reversibility of ‘conduct disorders’ in depressed children treated with Thymoleptic illustrate the importance of early energetic and specific pharmacologic therapies in preventing post-depressive personality disturbances. In brief, the characterological disturbances of borderline patients sometimes represent primary character pathology, but more often are secondary to an affective disorder or concurrent to such a disorder, i.e., to be coded on an axis orthogonal to the phenomenologic diagnosis,
Borderline conditions emerge as an enormously heterogeneous group of disorders that embrace the entire gamut of psychopathology. Proportions of specific subtypes in different studies are probably a function of the different populations sampled. Borderline conditions do not seem to represent a definable personality type, and, therefore, they don’t belong upon any measure of perturbative illnesses. As it is to suggest, that the potential utility of the concept might be explored on a distinct psychodynamic axis. In spite of an unwielding degree of diagnostic heterogeneity, the concept may still prove useful in setting the stage for a psychotherapeutic intervention gearing the common developmental vicissitudes and ego functioning of patients with certain low level defences best described in Kernberg’s work.
Yet it would seem that the very heterogeneity of disorders within the borderline realm argues against a unitary therapeutic modality. For instance, if the clinician were to consider pharmacologic approaches, one could make the case for tricyclics, MOA inhibitors, lithium carbonate, neuroleptics , stimulants, anticonvulsants - as well avoidance, of pharmacotherapy for the various subtypes.
Such is our current nosologic use of the concept of borderline seems to map a large universe of chronically and seriously ill ‘difficult’ patients outside the area of the ‘classical’ psychoses and neuroses. It is necessary to look beyond the characterologic ‘masks’ in order to appreciate the phenomenological diversity of these conditions. A specific personality type or psychophatholic entity as the proper noun for the borderline adjective has not been found. Like ;necrotic’ and ‘psychotic’, It has no place in modern descriptive psychopathology, there are simply too many neurotic and psychotic conditions which render futile all descriptive efforts to identify a specific ‘border ‘.
In a very literal sense then borderline personality can be considered to be a borderline diagnosis.
