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Record: 19



Title:
Borderline disorders in
children and adolescents: The concept, the
diagnosis, and the controversies.

Subject(s):
BORDERLINE personality disorder in children;
BORDERLINE personality disorder in
adolescence; CHILD sexual abuse -- Psychological aspects;
POST-traumatic stress disorder

Source:
Bulletin of the Menninger
Clinic, Spring94, Vol. 58 Issue 2, p169, 28p, 2
charts

Author(s):
Bleiberg, Efrain

Abstract:
Discusses the concept, diagnosis and
controversies of borderline personality
disorders in children and
adolescents. Existing ideas on the etiology of the
disorder; Psychodynamic, developmental and biological
theories; Family factors; Posttraumatic stress disorder as a
result of sexual abuse; Case examples.

AN:
9410253945

ISSN:
0025-9284

Note:
This title is not held
locally

Full Text Word Count:

10878

Database:
Academic Search Premier


BORDERLINE DISORDERS IN
CHILDREN AND ADOLESCENTS: THE CONCEPT, THE
DIAGNOSIS, AND THE CONTROVERSIES


The concept of borderline disorders in
children and adolescents remains controversial.
After reviewing the development of the "borderline" diagnosis,
the author discusses the concept of personality
disorders in children and clinical features of
borderline personality disorder. He also
highlights current ideas on the etiology of the disorder,
including psychodynamic, developmental, and biological theories, family
factors such as the effects of early loss or separation from parents, and
physical and sexual abuse. The author concludes by discussing the differences
and similarities between posttraumatic stress disorder as a
result of sexual abuse and borderline personality
disorder in children and
adolescents. (Bulletin of the Menninger Clinic, 58[2], 169-196)

In 1983 Pine reported that, in clinical practice, the flow of
children who were given the diagnosis "borderline" had reached
flood proportions. The "flood" has not receded, yet the concept of borderline
disorders in children and adolescents
remains mired in unclarity and controversy.
Beginning in the late 1940s and early 1950s, clinicians such as Mahler, Ross,
and DeFries (1949) and Well (1953) identified a group of "atypical"
children whose disturbance in ego functions and object relations
was less severe than that presented by psychotic children, yet
more serious than that displayed by neurotic children. Mahler and
her colleagues (1949) placed these children at the mild end of a
clinical and developmental continuum that extends to the most severe and
primitive psychotic conditions--the autistic and symbiotic psychoses of
childhood. Thus Mahler articulated the notion of "benign" or "borderline"
psychosis, a precursor to the idea of a schizophrenic spectrum in which
borderline conditions would represent an attenuated, incipient, or less severe
variant.
Ekstein and Wallerstein (1954) proposed the term "borderline" to designate
children who were not on the way to becoming psychotic but who
instead, presented a "characteristic pattern of unpredictability which is
paradoxically one of [their] most predictable aspects" (p. 345), constantly
fluctuating between a neurotic and a psychotic level of reality contact, object
relations, and defensive organization. Ekstein and Wallerstein thus advanced the
concept of borderline children as a stable clinical entity defined
precisely by ongoing and very rapid shifts in ego functioning.
These pioneer efforts stirred up a great deal of interest, primarily among
psychoanalytic writers, leading to a number of attempts to delineate more
systematically the developmental and clinical features characteristic of
borderline children. Geleerd ( 1958), Marcus ( 1963), Rosenfeld
and Sprince (1963), and Frijling-Schreuder (1969), among others, described
children presenting a wide and fluctuating array of problems,
including impulsivity; low frustration tolerance; uneven development; proneness
to withdraw into fantasy or to regress into primary process in response to
stress, lack of structure, or separation from caretakers; pervasive, intense
anxiety and multiple neurotic symptoms such as phobias, compulsions or
ritualistic behavior; somatic complaints; and sleep problems.
Otto Kernberg's (1975) influential contributions sought to
define borderline as a level of personality organization.
According to Kernberg, a number of personality
disorders, including the narcissistic, the schizoid, the paranoid,
and the antisocial, generally function at a borderline level of
personality organization. This broad, developmentally based use of
the term borderline resonated with similar notions evolving among clinicians
working with children. Pine (1974), for example, defined the
borderline conditions of children and adolescents as
a group of disorders with common developmental and structural
features but also with substantial differences in clinical manifestations and
etiology.
The successive editions of the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association [APA], 1980, 1987,
1993), on the other hand, striving for an empirical, atheoretical
classification, designated borderline as a specific personality
disorder--the borderline personality
disorder (BPD)--one of the cluster B or dramatic
personality disorders. This group also includes the
histrionic, the narcissistic, and the antisocial personality
disorders. According to DSM-IV (APA, 1993), BPD consists of "a
pervasive pattern of instability of interpersonal relationships, self-image,
affects, and control over impulses, beginning by early adulthood [emphasis
added]" (p. T:5).
DSM-IV's approach to the diagnosis of borderline personality
disorder raises several questions about its applicability to
children and adolescents: Are there enough empirical
data to support the notion of "borderline"--or BPD--as a distinct diagnostic
entity in childhood? More generally, is it valid to ascertain the diagnosis of
"personality disorder" in a child or an
adolescent? Personality disorders,
after all, are defined as relatively enduring and pervasively maladaptive
patterns of experiencing, relating, and coping. Yet children and
adolescents are engaged in very fluid developmental processes in
which every aspect of their bodies and personalities is constantly
changing, at different rates, creating new equilibriums and disequilibriums
within them and in their relationships with the environment. Maturation and
experience provide children with ever-changing tools to cope,
perceive, and organize their experience, and to relate to others, making it
difficult, if not impossible, to speak of "rigid and enduring patterns."
And even if personality disorders could be
diagnosed before adulthood, are there developmental and clinical continuities
between borderline children, borderline adolescents,
and borderline adults? Does "borderline" refer to a level of developmental
attainment, as Otto Kernberg (1975) and much of the literature on
children suggest, or is it a discrete disorder, as
DSM-III-R and DSM-IV advocate? Or is borderline, instead, part of a spectrum or
a continuum with other personality disorders, with
various degrees of overlap, as Adler (1981, 1985) suggests? Or should borderline
be considered a dimensional diagnosis, extending from less severe forms--perhaps
equivalent to the identity disorder of children and
adolescents--to more severe presentations? And lastly, what are
the links between borderline disorders and other common Axis I
diagnoses of children and adolescents, such as
conduct disorders, attention-deficit disorders,
eating disorders, substance abuse, separation anxiety, mood
disorders, and posttraumatic stress disorder (PTSD)?
The high prevalence of these Axis I diagnoses in borderline youngsters raises
the question of whether borderline is really an atypical, complicated, or severe
form of Axis I diagnosis. In particular, the very common finding of a history of
prolonged and repeated trauma--most significantly sexual abuse--in borderline
adolescents and adults raises the question (Goodwin, Cheeves,
& Connell, 1990; Herman, 1992) of whether "borderline" is little more than a
pejorative designation for individuals who suffer a complex PTSD syndrome as a
consequence of protracted abuse and victimization.
These questions are far from settled. In this paper, I will discuss these
issues with particular attention to: (1) the concept of
personality disorders in children; (2)
the clinical features of BPD in children and
adolescents; (3) current ideas about the role of
psychodynamic-developmental, biological, family interaction, and traumatic
factors in the etiology of BPD in children and
adolescents; and (4) differences and similarities between PTSD
secondary to sexual abuse and BPD in children and
adolescents.
Personality disorders in
children and adolescents
Can children's personalities become so rigidly
fixed in maladaptive patterns of coping, experiencing, and relating as to
qualify for the designation "personality disorder"?
Until recently, this debate has been largely fought in the arena of theoretical
dispute. Over the past 15 years, however, developmental research and prospective
developmental studies have provided an increasingly more refined, empirically
supported basis from which to understand how genetic and environmental forces
come together to generate, organize, and structure children's
subjective experience, coping mechanisms, and relationship patterns.
Such studies support Paulina Kernberg's (1990)
contention that children exhibit distinctive traits and patterns
of perceiving, relating, and thinking about the environment and themselves,
including traits such as egocentricity, inhibition, sociability, activity, and
many others. Kernberg added that these traits and patterns endure
across time and situation and warrant the designation of
personality disorder, regardless of age, when they
(1) become inflexible, maladaptive, and chronic; (2) cause significant
functional impairment; and (3) produce severe subjective distress.
Developmental research has begun to illuminate the processes that give rise
to enduring patterns of experiencing, coping, and relating. In particular,
research has focused on identifying the motivational forces giving direction to
development and the organizing tendencies that result in enduring patterns.
Along these lines, developmental research (Sameroff & Emde, 1992; Stern,
1985) demonstrates that the effort to create and maintain human connections is a
central, built-in human tendency and a critical organizer of psychological
experience. The innate tendency to search for two-way relationships and to crave
human reciprocity is indeed as peremptory a human motive as is the need for
food, tension reduction, or libidinal gratification.
Research also documents the existence of a powerful, innate bias toward
self-regulation and mastery, and a tendency to create perceptual-experiential
coherence and organization (Emde, 1989). Stern (1985) remarked that the human
brain is designed to put together what goes together in reality. Ample research
evidence supports the notion that infants are driven to construct mental models
of the world and of themselves in the world, and to experience distress when
they encounter a "mismatch" between reality and their mental model of it. For
example, when 3-month-old infants are presented with an image of their mother's
face on a television screen but her voice is delayed by a few hundred
milliseconds, the infants detect the discrepancy and are disturbed by it,
remaining upset until the discrepancy is corrected, that is, until what "goes
together" is put back together.
Experiments such as this suggest that infants (1) develop fairly realistic
spatial-temporal models of reality and use them to anticipate what reality will
be like, and (2) present a readiness to activate affective responses of anxiety
when reality fails to match their mental model of it. Such responses lend
support to Emde's (1989) view that affective systems are psychobiological
dispositions with both organizing and communicative functions. As an organizer,
the anxiety experienced after a "mismatch" induces efforts to create mental
models that can serve as increasingly more accurate predictors of reality.
In normal development, of course, efforts to gain mastery and achieve
experiential coherence are tightly interwoven with the pursuit of
object-relatedness. Sander (1975) made the point that an infant's competence is
contingent on the presence of alert and responsive caregivers. To achieve a
sense of mastery and to gain (or regain) experiential coherence, infants can
rely only on their capacity to signal distress and evoke attuned responses from
their caretakers. The caretaker's appropriate response, for example, to an
infant's signal of hunger transforms the infant's internal state from one of
hunger-and helplessness in the face of it--to one of satiation and regained
mastery and coherence.
Such transactional sequences--signal of distress, followed by attuned
response, followed by regained coherence--permit the restoration of
physiological homeostasis, reinforce the need to search for objects, and provide
sensual gratification. They also form the template for mental representations of
those sequences. Stern (1985) described how the infant's abstraction of the
common or invariant features of these transactional episodes leads to the
construction of what he calls "representations of interactions generalized"
(RIGs), which are then organized into "internal representational models" (IRMs)
of the self in relation to others. IRMs guide the infant's search for human
connections and the effort to anticipate reality's demands, and they form the
matrix of what we call personality: a psychological organization
underlying the individual's characteristic patterns of perceiving, experiencing,
relating, and coping.
The progression from IRMs to personality patterns follows the
growth of the child's symbolic and social competence during the second and third
years of life, which transforms the IRMs from tools to anticipate reality into
psychological systems to organize future interactions. For example, Sroufe
(1989) described 3- and 4-year-old children attempting to break
into a preschool dance at the Minnesota Preschool Project.
Children assessed at age 1 as anxiously attached are more likely
to be rebuffed when trying to break in. Following a rebuff, these
children typically sulk and crawl to a corner.
Children assessed as securely attached at age 1, on the other
hand, are less likely to evoke rejection. But even when rebuffed, these
children will not give up. Instead, they keep trying until they
succeed in breaking into the group. In this group of children,
there is far less evidence of feeling "rejection" but a remarkable persistence
until they manage to evoke an interpersonal response that matches their internal
model: They are worthy and effective and others are responsive.
Needless to say, this description of one aspect of intrapsychic development
fails to do justice to the complexity of developmental processes occurring
simultaneously. Of particular significance for our discussion is the
intersubjective context in which these developmental achievements unfold. In
normal development, the tendency to use intrapsychic models to organize one's
interpersonal reality becomes increasingly more elaborate, yet it is modulated
by a corresponding openness of the intrapsychic world to be modified by
interpersonal influences. This openness is illustrated by the phenomenon of
social referencing (Campos & Stenberg, 1981). Beginning in the second half
of the first year of life, infants respond to a novel or uncertain
situation-that is, one for which they lack an internal model--in a predictable
fashion: They search the caretaker's face for clues to resolve the uncertainty.
If the caretaker's face signals encouragement, the infants explore with
pleasure. If, however, the caretaker betrays anxiety, they become inhibited and
distressed.
Developmental research also points to how interpersonal clues serve as
templates for the construction of internal models. During the first few months
of life, children rely almost entirely on perceptual clues from
which they can identify temporospatial, "amodal" qualities (Stern, 1985), such
as rhythm, intensity, sequence, affect, and tone. Toward the end of the first
year of life, verbal-symbolic clues begin to gain ascendancy, leading to the
construction of representational models with symbolic qualities. These models
are therefore amenable to symbolic transformation for either defensive or
adaptive purposes. A growing body of evidence thus supports the notion that, in
normal development, a person's representational models are
constantly shaped by exchanges with other people's intrapsychic world of
representations, meanings, affects, and intentions.
The personality disorders are characterized by
particular patterns of distortion in the organization of experience, coping
mechanisms, and relationships. Common features of all personality
disorders include: (1) an extreme rigidity of internal
representational models; the normal two-way street between the intrapsychic and
the interpersonal is replaced by a desperate and rigid insistence that the
external world match and support a rigidly held intrapsychic configuration; (2)
an ongoing effort to "get rid" of experiences--whether internally or externally
generated--that challenge the person's intrapsychic models; and
(3) a persistent inclination to evoke responses in others that "fit" an inner
script instead of the flexible mutual adaptation that characterizes normal
relationships. Prospective studies such as those of Block and Block (1980) and
LaFreniere and Sroufe (1985) document how temperamental constellations, deviant
attachment patterns, and disturbances in early childhood relationships evolve
into extreme and precocious rigidity in relationships, coping mechanisms, and
experience.
Developmental research is thus beginning to validate Paulina
Kernberg's (1990) contention that children can
indeed present with personality disorders. More
specifically, and basing her assumptions largely on clinical experience,
Kernberg postulated the validity of the concept of borderline
personality in children under age 12. Undoubtedly,
as Shapiro (1990) has cautioned, a good deal of research is needed to establish
the validity and reliability of the BPD construct in childhood and
adolescence. The retrospective study of Greenman, Gunderson, Cane,
and Saltzman (1986), for example, questions our ability to discriminate between
borderline and nonborderline children. Yet more recent studies
(Goldman, D'Angelo, Demaso, & Mezzacappa, 1992; Ludolph et al., 1990)
suggest that semistructured interviews such as the Diagnostic Interview for
Borderlines (DIB) (Gunderson, Kolb, & Austin, 1981) and DSM-ILI-R criteria
can be applied to borderline children. Only careful longitudinal
follow-up will clarify whether children we call borderline will
indeed grow into adolescents and adults with BPD.
Clinical features of BPD in children and
adolescents
After reviewing the clinical literature, Bemporad and Cicchetti
(1982) and Vela, Gottlieb, and Gottlieb (1983) described substantial consensus
in diagnostic criteria for borderline children. Bemporad, Smith,
Hanson, and Cicchetti (1982) outlined diagnostic criteria consisting of the
following features: (1) a paradigmatic fluctuation of functioning, with rapid
shifts between psychotic-like and neurotic levels of reality testing; (2) a lack
of "signal anxiety" (Freud, 1926/1959) and a proneness to states of panic
dominated by overwhelming concerns of body dissolution, annihilation, or
abandonment; (3) a disruption in thought processes and content that shifts
rapidly into loose, idiosyncratic thinking; (4) an impairment in relationships,
with much difficulty, when under stress, in distinguishing self from others, in
appreciating other people's needs, or in integrating disparate emotional
experiences into a coherent relationship; and (5) a lack of impulse control,
with an inability to contain intense affects, delay gratification, control rage,
or modulate destructive and self-destructive tendencies. Vela et al. (1983)
described six features: (l) disturbances in interpersonal relationships; (2)
disturbances in the sense of reality; (3) excessive anxiety; (4) severe impulse
problems; (5) "neurotic-like" symptoms; and (6) uneven or distorted development.

More recently, Petri and Vela (1990) further refined the diagnostic criteria
by identifying two broad categories among children described as
borderline in the literature: the borderline personality
disorder (BPD)/borderline spectrum proper, and the schizotypal
personality disorder (SPD)/schizotypal spectrum.
Both groups present transient psychotic episodes, magical thinking,
idiosyncratic fantasies, suspiciousness, and a disturbed sense of reality. Yet
only schizotypal children have a family history of
schizophrenia-spectrum disorder or present constricted or
inappropriate affect, oddness of speech, and extreme discomfort in social
situations, which contrasts with the intense, dramatic affect and hunger for
social response of borderline youngsters. Petti and Vela's study parallels the
findings of genetic, epidemiological, and follow-up studies of adult BPD, all of
which separate the borderline spectrum from the schizophrenic-schizotypal
spectrum. Such a distinction is likely to result in much greater diagnostic
specificity with borderline children.
Children in the process of developing narcissistic or
histrionic personality disorders present significant
clinical overlap with children with BPl). Narcissistic and/or
histrionic children are self-centered and self-absorbed, need
constant attention, respond with rage to rejection or indifference, alternate
between idealization and devaluation, are seductive or manipulative, and express
affect with undue intensity and drama. This overlap supports the contention in
DSM-III-R that these personality disorders should be
clustered together. Borderline children, however, display much
greater impulsivity, self-destructiveness, affective instability, disturbances
in the sense of reality, and transient psychotic episodes, suggesting some
significant differences in developmental and pathogenic factors. Goldman et al.
(1992) proposed a slight modification of the DSM-III-R adult criteria for
borderline children (see Table 1).
Early manifestations of developmental difficulties are apparent in
children who subsequently develop BPI). History often reveals
temperamentally "difficult" children, that is, infants with high
activity levels, poor adaptability, negative mood, and problems settling into
rhythmic patterns of sleep-wakefulness and feeding. Cranky and hard to soothe,
these infants frequently challenge and burden their caretakers.
Hyperactivity and temper tantrums are common in the preschool years of many
borderline children, while others are more notable for their
clinginess and vulnerability to separations. By school age, borderline
children almost invariably meet diagnostic criteria for an Axis I
diagnosis, more commonly attention-deficit hyperactivity disorder,
conduct disorder, separation anxiety disorder, or
mood disorder. Many of these youngsters appear anxious, moody,
irritable, and explosive. Minor upsets or frustrations trigger intense affective
storms--episodes of uncontrolled emotion wholly out of proportion to the
apparent precipitant. This lability of affect mirrors the kaleidoscopic quality
of these children's sense of self and others. One moment they feel
elated and expansive, blissfully connected in perfect love and harmony to an
idealized partner. But at the next moment, they plunge into bitter
disappointment and rage, coupled with self-loathing and despair.
On clinical examination, borderline school-age children may
appear helpless and vulnerable, provocative and suspicious, or eager to comply
and ingratiate themselves with the examiner. Leichtman and Nathan (1983)
described how these youngsters quickly attempt to establish highly coercive,
controlling relationships with their examiners. Some show surprisingly little
anxiety about meeting alone with the clinician and proceed to take over the
office as if they owned it. Even those who seem vulnerable and anxious try
vigorously to set the agenda for the meeting. They become anxious and even more
desperate and arbitrary when the examiner does not comply with their demands or
when they feel that their control is threatened.
Borderline youngsters require a constant stream of emotional
"supplies"--someone's love and attention, sex, drugs, or food--to protect them
against overwhelming feelings of dyscontrol, hyperarousal, and aloneness. These
supplies can transiently stave off such dreaded emotional whirlwinds. But when
they are not forthcoming, these children panic, become enraged or
temporarily psychotic, or experience an unbearable sense of basic disconnection
from human nurturance and protection.
Thus these children direct much of their energy at coercing
others to provide them with the "right" supplies and responses. Such efforts
often take the form of elaborate maneuvers to induce others to assume particular
roles that "fit" elaborate fantasies. As Chethik and Fast (1970) pointed out,
these children become absorbed in a vivid fantasy world and demand
that others become players in this world they have created. Although these
children can generally recognize the arbitrariness with which they
treat people and reality itself, they behave as if they must believe their own
falsification of reality. It is in the enactment of their fantasies--whether in
play or in their relationships--that they come to life, while they adamantly
forbid reality to intrude and to question the arbitrariness they impose on
reality. This rigid and desperate insistence on inducing interpersonal responses
that support an illusory perspective is one of the most draining challenges
facing clinicians working with such youngsters.
Case example
Cory, a Taiwanese-born 8-year-old girl, was adopted as a baby by a Caucasian
family from the Midwest. Threats of separation from her adoptive mother--for
example, the prospect of the mother visiting her sister for a weekend in a
nearby city--triggered a dramatic disruption in Cory's contact with reality, as
well as rage outbursts, fits, and tantrums both at home and in school. Cory also
created a fantasy in response to her mother's absence: She "knew" that her
biological mother was an Asian princess.
This fantasy was extraordinarily vivid for Cory, causing her to lash out at
the world when it failed to appreciate her entitlement to royal prerogatives.
Yet, even without reality's challenge, a dream or a bad thought typically
sufficed to disrupt the idyllic fantasy. In Cory's dreams and play, the
"princess" would be replaced by a witch, a vicious vixen whose facial appearance
combined Asian and Caucasian features. This woman taunted Cory and tried to drag
her into a bottomless pit, leaving the child with no choice but to strangle the
witch. As Cory's fantasy unraveled, Cory also changed. When unable to invoke the
princess--and to demand that others such as her mother or therapist "become" the
princess--Cory would turn into a "Chinese bitch," filled with rage and
destructiveness.
Cory's attempt to produce a perfect, magical union, while keeping safely
apart the dangerous, rageful, and frustrating aspects of herself and others,
often fell apart in the face of separation or the threat of loss of control. The
collapse of such fantasied scenarios is one of the triggers of self-mutilation
and suicidal gestures, which are also brought about by: (1) attempts to restore
the capacity to experience feelings in children haunted by
emotional numbness; (2) efforts to escape unbearable anxiety and depression; (3)
desires to punish previously idealized partners; or (4) maneuvers to evoke guilt
and involvement.
The psychological landscape of these youngsters can sometimes be glimpsed
only through the lens of psychological testing. According to Leichtman and
Nathan (1983), psychological testing reveals rigid and tenuous repressive
defenses, coexisting with primitive defenses; a highly egocentric, arbitrary
interpretation of reality; transitory disturbances in reality testing and
impairments in formal thought processes in unstructured tests; constant or
recurrent disturbances in ego functions such as frustration tolerance,
attention, and goal-directedness; primitive, unmodulated experience of affects
and drives; and marked disturbances in interpersonal relationships and in the
experiences of self and others.
The developmental and psychosocial pressures of adolescence
typically trigger the onset of the full range of borderline psychopathology and
allow for greater diagnostic certainty. Unstable relationships with peers become
prominent as transient idealization and clingy overdependence alternate with
rage, devaluation, and feelings of abandonment and betrayal. Regardless of
whether idealization or anger predominates, all of these youngsters'
interpersonal exchanges have an intense, dramatic quality. Promiscuity is more
common in borderline girls, particularly sexually abused girls for whom
aggressive seductiveness affords the opportunity to turn around and gain control
of the helplessness associated with being abused. Borderline boys are often
burdened with intense shyness and fear of rejection. Manipulative efforts to
secure attention and prevent abandonment become prominent interpersonal
strategies for both boys and girls. Bulimic binges or drugs are relied on for
soothing and comfort, and become essential regulators of well-being. Yet the
transient nurturance derived from food binges, drug abuse, or promiscuous sex
leads only to shame, guilt, and a dreaded feeling of inner deadness or
emptiness.
Etiology and pathogenesis
Psychodynamic and developmental theories
A range of related hypotheses have emerged from the psychoanalytic literature
to explain the etiology of borderline personality and BPD in
children and adolescents. Mahler's (1971; Mahler,
Pine, & Bergman, 1975) ideas about the separation-individuation process and
Otto Kernberg's (1967, 1975) notions about splitting have provided
the most influential conceptual framework for psychodynamic clinicians.
According to Mahler, children between 12 and 36 months of age
go through a series of stages during which: (1) they internalize some of the
soothing, equilibrium-maintaining functions previously performed exclusively by
the parents, thus acquiring the capacity to carry out these functions with some
degree of autonomy; (2) they practice ego skills and use them to expand their
knowledge of themselves and the world and to figure out how to evoke desired
responses from the environment; and (3) they integrate the "good" and the "bad"
representations of the self and the object. These achievements, in turn, permit
children to accept the reality of their existence as separate
individuals and to develop object constancy, which refers to the ability to
maintain relationships and evoke the loving and comforting image of the object
in spite of separation or frustration.
Both Mahler and Kernberg believe that derailment of this
developmental process results in borderline psychopathology. For
Kernberg, the basic pathogenic factor is excessive aggression,
whether derived from a constitutional propensity or secondary to undue early
frustration, which leads to a predominance of negative introjects. The child's
aggressive introjects threaten to destroy the "good" images of the self and the
object, fostering the defensive need to maintain a split of the good and bad
representations. The central feature of borderline pathology, according to
Kernberg, is the ongoing effort to hold on to an "all good" or
idealized image of the self and the object in the face of unremitting assault
from "all bad" introjects, activated by separation, frustration, or the object's
failure to live up to ideal expectations.
Masterson and Rinsley (1975) claimed that specific patterns of mother-infant
interaction thwart the separation-individuation process and lead to borderline
psychopathology. In their view, the mothers of future borderline individuals
take pride in and find gratification in their children's
dependency. These mothers reward passive-dependent, clinging behavior while
withdrawing or otherwise punishing their children for actively
striving for autonomy. They carefully attune to states of helplessness and
proximity-seeking behavior but give subtle or overt rebuffs when their
children show evidence of mastery or independence. The central
message communicated to these children, said Rinsley (1984), is
that to grow up is to face "the loss or withdrawal of material supplies, coupled
with the related injunction that to avoid that calamity the child must remain
dependent, inadequate, symbiotic" (p. 5).
Such selectivity of maternal response and attunement fosters a split of the
maternal representation into two components: one rewarding and gratifying in
response to dependency, and the second punitive and withdrawing in response to
autonomy, mastery, and separation. This representational split and the
associated inhibition of autonomy come to the fore at times when developmental
and psychosocial pressures push toward separation, particularly during
adolescence.
Adler (1985) postulated that the central feature of borderline
psychopathology is the patient's inability to evoke the memory of a soothing,
comforting object when facing separation or distress. Adler attributed this
defect in internalization to parental failure in providing an adequate "holding
environment," as described by Winnicott (1965). The consequence is an inner
sense of emptiness; reliance on transitional objects and activities, similar to
the early transitional experiences described by Winnicott (1953), such as drugs
or food to provide soothing and comfort; and angry, manipulative efforts to
produce involvement and attention from others.
Gabbard (1994) cogently summarized the controversies and critiques
surrounding the psychodynaxnic models of BPD. He pointed out the overemphasis in
most psychodynamic models on early development, particularly the
separation-individuation process, at the expense of other, also sensitive
developmental stages, such as the oedipal phase and adolescence.
Equally significant is the lack of consideration of constitutional
factors--except for Otto Kernberg, who has been criticized for
ascribing too much significance to constitutionally based aggression.
Constitutional vulnerability plays a major role in shaping the child's
developing intrapsychic world by affecting the negotiation of developmental
tasks and by influencing parental responses--which in turn influence the child's
experience. Psychodynamic hypotheses also tend to exaggerate maternal
responsibility and largely ignore the role of others--particularly neglectful
and/or abusive fathers--in the pathogenesis of BPD.
Biological theories
For the past 15 years, a growing consensus has emerged regarding the
significance of biological factors in the etiology of borderline
personality disorder. Specific biological
vulnerabilities both shape the intrapsychic development of
children with BPD and evoke the interpersonal responses that
maintain, reinforce, or exacerbate the intrapsychic configuration of these
children. A recent study (Goldman, D'Angelo, & DeMaso, 1993)
found much higher rates of parental psychopathology in children
with the diagnosis of BPD. Goldman et al.'s findings parallel the reports of
higher rates of depressive disorders, antisocial
personality, and substance abuse disorders in the
families of adults with BPD. Although these reports suggest a biological
diathesis, spelling out the nature of this vulnerability remains controversial.
Klein (1977) first proposed that at least a subgroup of borderline patients,
whom he referred to as "hysteroid dysphorics," suffer from a problem in
affective regulation that gives rise to emotional lability and heightened
sensitivity to rejection. According to Klein, manipulative relationships and
other maladaptive interpersonal tactics and object relations result from rather
than cause the affective dysregulation. This view gained strength after the
studies of Stone (1979), Stone, Kahn, and Flye (1981), and Akiskal (1981). Stone
found a high prevalence of affective disorder in the relatives of
borderline patients, but no increase in schizophrenia-spectrum
disorders. Akiskal identified features suggestive of borderline
personality disorder in the offspring of affectively
ill patients, and proposed that these patients may represent an atypical or
incipient form of affective disorder.
These studies helped to distinguish borderline personality
disorder from schizophrenia and suggested instead a connection
with the mood disorders. More recent studies, summarized by
Gunderson and Zanarini (1989), have confirmed an elevated prevalence of mood
disorders in the relatives of borderline probands, but have also
pointed out that a linkage between borderline personality and mood
disorders is neither uniform nor strong. Yet, for a significant
number of borderline children, a vulnerability to mood
disorders appears to greatly heighten their chances for major
disruptions in personality development and to strongly predispose
these children to develop BPD.
Case example
Travis illustrates the plight of these children. His birth was
haunted by the suicides of his father, a paternal uncle, and a paternal
grandfather, all suffering from bipolar disorder. Travis's father,
also named Travis, had pleaded with his wife to have an abortion. When she
refused, he had hanged himself--three months before Travis's birth. Travis later
was told that his father had "gotten so excited when he found out that Travis
was coming" that his blood pressure went "sky high" and he died of a heart
attack. Not surprisingly, the boy became convinced that he had killed his
father.
Mood lability was Travis's most striking clinical feature when he was brought
for consultation at age 7. One moment, he bubbled with enthusiasm, swept up by
an elated mood while his thoughts raced ebulliently. Yet minor mistakes or
frustrations triggered fits of rage or led him to plunge into abject ignominy
and self-hatred. Constant vigilance was needed to prevent him from hurting
himself in one or another "accident."
A trial of mood stabilizing medication resulted in a significant decrease in
the boy's affective storms. Yet his developmental difficulties remained
glaringly apparent. His sense of self and others appeared like an ever-changing
kaleidoscope. He valiantly tried to hold onto an image of himself as the heroic
savior and protector of his beautiful mother. This image, however, was
constantly besieged by a hateful introject of a guilt-inducing, self-absorbed,
depriving mother, with whom he was locked in a rageful embrace.
A proneness to irritability, mood lability, and anger seems clearly to
interfere with the development of a cohesive sense of self and object constancy.
Rage promotes the need to rely on splitting to protect even a semblance of good
internal relationships. Just as surely, these frustrating, difficult-to-comfort
children burden parents with anger, shame, and guilt feelings.
Both the parents, who are often vulnerable themselves to mood and
personality disorders, and their
children end up caught in coercive cycles of hatred and rejection,
followed by desperate attempts to recreate blissful reunions.
Other borderline youngsters present a different kind of impulse-control
problem. The child psychiatric literature has long emphasized the "atypical ego
development" (Weil, 1953), impulsivity, and learning problems of many borderline
children. A clinical overlap is readily apparent between the
symptoms of the disruptive behavior disorders--particularly
attention-deficit hyperactivity disorder, conduct
disorder, and BPD. Along these lines, Andrulonis et al. (1981) and
Andrulonis (1991) reported on the link between learning disabilities, episodic
dyscontrol, or disruptive behavior disorders in
children and BPD in adults.
A neuropsychological impairment, such as ADHD, and/or a cognitive processing
problem, such as a developmental reading disorder, can affect
children's development in a number of ways. In particular, it can
produce a significant distortion of the experience of intention (Shapiro, 1965).
In normal children, impulses, wishes, and whims initiate a complex
process, usually carried out smoothly and automatically outside conscious
awareness. First, the impulse's expression is inhibited. Subsequently, the
impulse commands or fails to command attention, then gains or loses significance
as it is balanced against and integrated into the person's more
enduring aims, values, and motivational constellations. These stabilizing
psychological systems are based on the child's mental representations of the
self in relationship with others. In other words, the nonimpulsive individual
"asks" himself or herself: "How does this wish of the moment fit with what is
going on now in my life, with my goals, ideals, and relationships, with who I am
and with what I wish to become?"
Such processing allows for a momentary impulse to be: suppressed, delayed in
its expression, repressed (when found to be too discordant and threatening to
the person's self-concept), displaced or modified into more
acceptable pursuits, or given access to action. This very processing transforms
the whim or urge of the moment into a more sustained and active experience of
decision. By virtue of this silent process of integration, individuals develop a
sense of agency and ownership over their behavior. The capacity to experience
guilt is one of the corollaries of assuming ownership over one's motives and
impulses.
In the case of impulsive children--and adults--their wishes,
needs, and impulses are translated directly into action, short-circuiting the
mediating process. Because they rush into action, their own wishes cannot evolve
into sustained intentions anchored in a sense of stability and self-continuity.
In fact, their chronic lack of integration of wishes, needs, and motives
disrupts their capacity to develop a cohesive and continuous sense of self and
others. Their low tolerance for frustration stems from an inability to connect
or integrate momentary wishes with general goals and interests, or to form
enduring representations of the self and others.
With impulsive youngsters, their actions "happen" to them instead of
resulting from their choice, and thus they experience little sense of guilt or
responsibility. The world appears as a disconnected set of temptations and
frustrations, possibilities for immediate gain and satisfaction, or obstacles to
gratification. They experience other people and relationships in equally
fragmentary and shallow ways, which results in an inner life that is barren and
undifferentiated.
Marohn, Offer, Ostrov, and Trujillo (1979) and Offer, Marohn, and Ostrov
(1979) conducted a factor analysis of a sample of juvenile delinquents and
concluded that "borderline" and "impulsive" constitute two of four overlapping
psychological subtypes found in the sample. As Marohn (1991) noted, many of
these youngsters have "little awareness of an inner psychological world, cannot
name affects or differentiate one affect from another, and often confuse
thought, feeling and deed" (p. 150). Their concrete, egocentric mode of
experience interferes with planning, abstraction, and generalization, and forms
the basis for their well-known difficulty in learning from experience. Of
course, these impulsive, angry youngsters fuel the chaos that often prevails in
their families, exhausting their parents and imposing all added burden of
frustration and distress while wreaking havoc with what little structure and
boundaries their families can offer.
A constitutional proneness to excessive separation anxiety may also play a
role in the pathogenesis of BPD in children. Kandel (1983) pointed
out a neurobiological readiness to trigger a response of anxiety and
hyperarousal in response to the absence of caretakers. The reappearance of
caretakers, on the other hand, evokes a "down regulation" of the alarm system in
response to a ready-to-be-activated signal of safety.
Mothers have always known intuitively that infants vary greatly in their
"sturdiness" and overall vulnerability to separations. Primate research (Suomi,
1987, 1992) has begun to substantiate such intuition. Baby monkeys vary
enormously in their hormonal, autonomic, emotional, and behavioral responses to
stress, particularly the stress of separation from caretakers. Such variations
are also likely in human infants, supporting the contention that separation
anxiety disorder has an important constitutional basis.
Children with extreme responses to separation are buffeted by
panic and hyperarousal after instances of parental "abandonment" that would be
quite manageable for less vulnerable youngsters. Parental unavailability is
utterly devastating for them and promotes clinginess and a desperate need to
ensure parental proximity. Parental overinvolvement in these instances may
reflect an adaptation to children's fragility rather than an
inability to tolerate independence.
As they grow, these anxiously attached (Ainsworth O Bell, 1974) youngsters
carry forward an image of themselves as helpless and incompetent, while they
experience others as unavailable, indifferent, or withholding. Rage sometimes
turns into disruptive and self-destructive behavior. Inflicting pain on oneself
and causing misery to others can effectively ensure responsiveness from
otherwise exhausted or frustrated parents. Thus dramatic behavior, including
outwardly and inwardly directed destructiveness, may become the currency of
relatedness every bit as much as it represents a protest against perceived
neglect, an unconscious search for confirmation of badness, and an expression of
a biologically based predisposition to mischief.
But a straight line cannot be drawn between any of these constitutional
vulnerabilities and BPD. Clearly, most children with ADHD, mood
disorder, or separation anxiety do not become borderline just as
surely as some borderline children appear free of these
vulnerabilities. Biological factors can be related to BPD in at least two
general ways: (1) developmental association: a major vulnerability, such as
ADHD, chronic and present from birth may greatly increase the likelihood of
other problems, burdening families and affecting many spheres of development,
thus creating a cascade of negative events that can result in BPD; or (2)
ascertainment bias: biological vulnerabilities may multiply the symptoms that
disturb others or increase the severity and adjustment difficulties of
borderline children, enhancing the chance of bringing borderline
children to diagnosis and treatment. Thus clinical surveys of
borderline children may overestimate the prevalence of biological
factors.
Understanding the pathogenic role of biological factors in BPD also thrusts
us into the realm of a transactional perspective: Biological factors play an
important part in shaping children's experience of themselves and
of others; of their competence and of other people's reliability; of the
"safety" or lack of safety of their emotional responses; and of their ability to
monitor emotional signals from themselves and from others, to cue others about
internal states, and to create states of emotional reciprocity. Biological
factors also modify the specific conditions that optimally promote each
individual child's development--greater or lesser closeness, limits, structure,
and so forth. Last, but not least, biological factors (e.g., irritability, poor
adaptability, impulsivity, and overactivity) influence parents and shape the
parenting that, in turn, shapes children's development-amplifying
or minimizing biological vulnerabilities.
Family environment and trauma
A major focus of recent research with adult patients with BPD has been the
search for specific features in their early family environment. Highly
conflictual relationships with mothers, uninvolved fathers, neglectful yet
controlling parenting, and chronic discord between the parents are often
reported by these patients (Frank & Paris, 1981; Goldberg, Mann, Wise, &
Segall, 1985; Paris & Frank, 1989; Paris & Zweig-Frank, 1992). Links
(1990) has suggested that when both parents fail to carry out their parental
functions, such biparental failure-particularly when coupled with earlier
abuse--results in borderline personality disorder.
Because these studies rely on retrospective data, their validity is open to
question. Systematic studies of the families of borderline
children are lacking, although clinical accounts describe parental
overinvolvement and resistance to children's autonomy and
separation. Two sets of issues have gained increasing prominence as possible
pathogenic factors: early loss or separation from the parents, and physical and
sexual abuse.
Parental loss or separation
The fact of the death of a parent is less vulnerable to retrospective
distortion. Thus the repeated finding of a history of parental loss during
childhood (Stone, 1990; Zanarini, Gunderson, Marino, Schwartz, &
Frankenburg, 1989) may be of significance. In a study of adult borderline
patients, for example, Stone (1990) identified three subgroups of borderline
patients in which approximately 60% had experienced early parental loss:
borderline patients who committed suicide, borderline patients with antisocial
personality comorbidity, and schizophreniform-borderline patients.

The impact of a parent's death on children's development has
been extensively reviewed in the child psychiatric and
psychoanalytic literature (Bleiberg, 1991; Furman, 1974; Nagera, 1970;
Wolfenstein, 1966). Jay's case (Bleiberg, Jackson, & Ross, 1986) illustrates
how a 13-month-old boy's loss of his mother set the stage for a
borderline-narcissistic organization, with significant implications in terms of
the boy's gender identity, object constancy, defensive mechanisms, and, more
generally, his ability to negotiate the tasks of development from
separation-individuation to the Oedipus complex and beyond.
Although there are significant disagreements about the specific impact of
early parental loss and psychopathology, most authors agree that parental loss
is, by definition, a significant developmental interference (Nagera, 1970).
Children require parents to provide psychological regulation and
to function as direction-givers, limit-setters, consistent protectors and
soothers, interpreters of reality, and facilitators of growth. As Furman (1974)
has noted, "the loss of the vital love object endangers both the building up of
the personality and the varied narcissistic satisfactions derived
from its functioning" (p. 53). Interactions with parents form the template in
which critical psychological capacities, such as effective self-esteem
regulation and object constancy, are forged. Such capacities are essential if
children are to achieve meaningful intrapsychic autonomy.
Children's ego states following the loss of a parent seem to
cluster in two patterns: (1) one characterized by fear, helplessness, loss of
control, passivity, deflated self-esteem, loneliness, and shame; and (2) one
dominated by rage, hyperactivity, withdrawing numbness, efforts at
self-sufficiency, rejection of others' help, emotional distance, failure to seek
comfort at times of stress, lack of concern with reciprocity and fairness,
involvement in exploitative relationships, and expectations of rejection. Two
overlapping pathological constellations may evolve out of these two initial
patterns: (1) one presenting prominent antisocial and narcissistic features;
this constellation represents the crystallization of defensive efforts designed
to disown narcissistic vulnerability, helplessness, and loneliness; and (2) a
second constellation dominated by the borderline-depressive collapse of the
efforts to prevent helplessness and restore a sense of mastery and connection
with others.
Of course, only a fraction of children who experience the loss
of a parent become borderline or develop other forms of psychopathology. This
fact supports the conclusion that the pathogenic impact of early parent loss
does not depend on the loss alone but is mediated by factors such as gender of
child and parent, child's age at the time of the parent's death, quality of the
preexisting relationship, available supports, and, particularly, the change the
parent's death introduces into the child's family.
A number of studies (e.g., Breier et al., 1988; Harris, Brown, & Bifulco,
1986) suggest that the chances of subsequent psychopathology are largely
determined by the cascade of adverse events precipitated by the death of a
parent: protracted depression and unavailability of the surviving parent,
financial hardship, disruption of household routines and structure, inconsistent
limits, and erratic demands for maturity. In more extreme circumstances,
overwhelming stress and social isolation in the surviving parent result in
suicidal behavior; substance abuse; verbal, physical, and/or sexual abuse; or
parentification of the children (Bleiberg, 199l).
Physical and sexual abuse
Physical and especially sexual abuse has emerged in the recent literature as
a major antecedent of BPD (Goodwin et al., 1990; Herman, 1992; Herman, Perry,
& van der Kolk, 1989). Indeed, when clinicians open for clinical scrutiny
the possibility of sexual abuse, an astonishing number of borderline
adolescents reveal lives marred by abuse. Theirs is not an empty
house, it is a haunted house (Zanarini et al., 1989), a house often filled with
the terrifying ghosts of caretakers' brutality and boundary violations.
Like other traumatic experiences, abuse renders children
passive and helpless in the face of a terrifying event. Such experiences are not
amenable to integration into what Freud (Breuer & Freud, 1893-1895/1955)
called "the dominant mass of ideas" (p. 116), that is, children's
internal representational models. No longer can children use
internal models to anticipate, let alone organize, their interpersonal world,
and thus they find themselves thrown into a state of passivity and subjective
dyscontrol, left with the challenge of assimilating and giving meaning to their
experience and of restoring a sense of activity, coherence, and control.
The states of terror and dyscontrol accompanying trauma evoke hyperarousal.
Under extreme circumstances--or in less extreme circumstances in
children with a strong constitutional predisposition-this altered
state of arousal leads to dissociation (Chu & Dill, 1990; Putnam, 1991,
1993; van der Kolk, 1987), which exists on a continuum with the "going into
automatic pilot" that characterizes most normal responses to life-threatening
emergencies. Learning that takes place in the state of hyperarousal and
dissociation is concrete and remains compartmentalized, instead of being
integrated and symbolized as part of internal representational models. The
working through of trauma involves the "undoing" of such compartmentalization
and the establishment of symbolic processing of the traumatic memories as they
are integrated into the representational models people use to give meaning to
their experience and engage in symbolic exchanges with others.
Yet sexual and physical abuse overwhelms children's egos with a
special perniciousness. The perpetrators of sexual and/or physical abuse are
often the very same people whom children rely on to help them
bring coherence to and ascribe meaning to their experience--their caretakers. An
abundance of research (Pynoos et al., 1987) demonstrates that
children respond more severely and are less able to assimilate
traumatic experiences when a family member is the agent of the trauma. Fear of
retribution, loyalty conflicts, and concerns about destroying or bringing shame
to the entire family militate against disclosure and working through. Confusing
feelings of arousal, pleasure, and specialness mix with terror, pain, rage,
shame, and helplessness, adding to the burden of children trying
to make sense of their plight.
Furthermore, sexual and physical abuse becomes entangled in the struggles and
conflicts of development, including fears of abandonment, concerns about
autonomy and ownership of the body, oedipal competition, and wishes to seduce
parents. Such entanglement hinders integration of the experience and fuels
feelings of estrangement from self and disconnection from others.
Memories of terrifying, abusive events remain in prolonged, unintegrated
storage, constantly threatening to intrude and evoke new states of shock,
helplessness, hyperarousal, dissociation, loneliness, rage, and shame. Such a
constellation, together with the high incidence of reports of sexual abuse in
the background of borderline children and
adolescents (Famularo, Kinscherff, & Fenton, 1991; Goldman et
al, 1992), supports the view that BPD is a complex form of PTSD. In Terr's
(1991) view, children's repeated traumatization--such as repeated
exposure to physical or sexual abuse--evokes defensive operations and
experiential distortions that lead to personality
disorders.
This point requires qualification. Even the highest estimates of sexual abuse
in adults with BPD (Herman et al., 1989; Ogata, Silk, & Goodrich, 1990;
Stone, 1990) are in the range of 60-80%. Such estimates point out that sexual
abuse is not necessary for the development of BPD. Furthermore, while sexual
abuse is widespread, afflicting a rather large percentage of the general
population, BPD is a far more circumscribed phenomenon. Sexual abuse is thus not
sufficient for the development of BPD. More significantly, although some
borderline children also meet diagnostic criteria for PTSD
(Famularo et al., 1991), significant differences can be found between PTSD and
BPD and other personality disorders in which trauma
also plays a major pathogenic role.
The personality disorders represent an active
effort at psychological organization, in effect, a "turning around" of the state
of traumatic helplessness. Children create enduring and
maladaptive patterns of defense, experience, and relationship (i.e.,
personality disorders) to ensure some measure of
mastery, control, and connection with others in the face of traumatic
helplessness and inner vulnerability.
The traumatic helplessness chronically experienced by borderline
children appears to be brought about by an intricate combination
of a broad genetic predisposition and an equally broad range of opmentaldevel
problems. The genetic contribution may consist of a vulnerability to mood
disorders, ADHD and/or learning disabilities, depression, or
separation anxiety. Developmental problems include early parental loss, sexual
and physical abuse, parental incompetence and neglect, and general
discouragement of separation and autonomy. The final outcome is also influenced
by the children's relative strengths and weaknesses and individual
traits (e.g., proneness to dissociation, propensity to experience rage, ability
to symbolize and integrate experiences).
Traumatic states may become transitional factors leading to borderline
personality disorder (see Figure 1). Borderline
children, for example, transform their conviction that misery,
passivity, and helplessness will befall them into the active pursuit of
self-victimization. Thus, paradoxically, self-victimization induces a secret
sense of power and control, and reverses traumatic states of helpless passivity.
Furthermore, these children will no longer wait for the abuse to
happen to them, but instead become extremely skillful at evoking abuse. Rather
than wait for hyperarousal, they will actively seek out thrills and excitement
and/or use a variety of means--food or drugs, for example-to numb themselves.
Numbing can also occur in a kind of self-hypnosis, which mitigates pain and
brings dissociative experiences under the youngster's "control." Terr (1991)
described a boy who coped with his stepfather's abuse by inducing a
self-hypnotic state during which he thought of sitting on his mother's lap
having a picnic in a beautiful park.
Splitting represents another enduring mechanism to actively provoke the very
fragmentation in the experience of self and other that these youngsters fear to
accept passively. Thus splitting can help children to create an
illusion of control, as much as to preserve the "good" object from the onslaught
of their rage. Children also turn the profound aloneness that
accompanies traumatic events into manipulative efforts to secure attention and
involvement from others. Manipulative relationships, in turn, become a vehicle
to express anger. But these children's rage turns into
entitlement: The world owes them something because they have suffered so much. Table 1. Adapted childhood criteria for borderline personality
disorder

1. A pattern of unstable and intense interpersonal relationships
characterized by alternation between extremes of
overidealization and devaluation and/or marked distortion of
the nature of the relationship.

2. lmpulsiveness in at least two areas that are potentially
self-damaging (e.g., reckless risk taking, running away,
stealing, substance abuse, sex, binge eating).

3. Affective instability: marked, rapid shifts from baseline mood
to depression, irritability, or anxiety lasting less than a few
hours and only rarely more than a few days; episodes may
include transient distortions of reality.

4. Inappropriate, intense anger or lack of control of anger (e.g.,
frequent displays of temper, constant anger, recurrent physical
fights).

5. Recurrent suicidal threats, gestures, or behavior or
self-mutilating or self-endangering acts.

6. Marked and persistent disturbance in self-perception and
self-presentation characterized by confusion regarding two of
the following: gender identity or roles, friendships, socially
appropriate behaviors, school or career plans, self-image.

7. Chronic feelings of emptiness or boredom.

8. Frantic efforts to avoid, or major preoccupation with, real or
imagined abandonment (do not include suicidal or
self-mutilating behavior covered in item 5).
From Goldman et al., 1992, p. 1724 Figure 1. Transitions between traumatic states and borderline
personality disorder.

Traumatic state Borderline personality disorder

Subjective dyscontrol and Self-victimization
passivity

Hyperarousal Thrill seeking and/or numbing

Dissociative tendencies Self-hypnosis and/or splitting

Aloneness Interpersonal manipulation

Rage Entitlement
This article is based on a presentation at the 15th annual Menninger Winter
Psychiatry Conference, held March 7-12, 1993, at Park City, Utah. Dr. Bleiberg
is executive vice president and chief of staff of The Menninger Clinic. Reprint
requests may be sent to Dr. Bleiberg at The Menninger Clinic, PO Box 829,
Topeka, KS 66601-0829. (Copyright * 1994 The Menninger Foundation)
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By Efrain Bleiberg, MD

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