Borderline Personality Disorder: A Comprehensive Guide

Subtypes of Borderline Patients (Grinker et al. 1968)

Type I: Borderline Psychotic

• Conduct: maladaptive and inappropriate
• Problems with reality testing and sense of identity
• Negative and openly expressed anger

Type II: Central Borderline

• General negative affect
• Vacillating commitment
• Performance of anger
• Inherent identity

Type III: Group as If

• Tendency to copy the identity of others
• Lack of affection
• More appropriate conduct
• Relationships lacking genuineness and spontaneity

Type IV: Borderline Neurotic

• Anaclitic depression
• Anxiety
• Neurotic and narcissistic traits

No Symptoms of Boundary Structures (According to Kernberg)
1. Anxiety: Diffuse and floating
1.Polysymptomatic Neurosis

• Multiple phobias
• Obsessive-compulsive symptoms
• Multiple conversion symptoms
• Dissociative reactions
• Hypochondriasis
• Paranoid tendencies
• Polymorphous perverse sexual tendencies

Symptoms Adjoining Structures (According to Kernberg)
4.Classic Prepsychotic Personality Structures. These include:

• Paranoid personality
• Schizoid personality
• Hypomanic and cyclothymic personality with strong hypomanic tendencies

• Addictions and impulse control disorders
• Lower-level character disorders
  • Chaotic and impulsive
  • Child-like personalities
  • Narcissistic personalities
  • Self-absorbed personalities
  • Antisocial personalities

The Spectrum of the Boundary

(Assumption of possible characterological structures)
High Borderline Structure

• Masochistic personality with depressive tendencies
• Hysteroid personality with dissociative and somatization symptoms
• Narcissistic personality
• Cyclothymic personality

The Spectrum of the Boundary

(Assumption of possible characterological structures)
Low Borderline Structure

• Prepsychotic personalities with schizoid and paranoid symptoms
• Insecure personality with severe obsessional symptoms (pseudoneurotic)
• Hypomanic personality
• Antisocial personality
• Insecure personality with hypochondriac tendencies
• Child-like character with self-mutilation tendencies

Structural Diagnosis I

Structural Diagnosis II

Negation in borderline patients is exemplified by the presence of emotionally independent areas of consciousness.

Structural Diagnosis III

The structure of the superego in these patients is primitive and sadistic, imposing high standards that generate guilt and a permanently devalued self-image and self-injurious behavior. Sometimes a superego manifests in integrated persecutory moments and at other times it is extremely lax, allowing uncontrolled serious impulses (robbery, assault, promiscuity), which in turn maintain a vicious cycle of persecutory blame and excesses.

No DSM-IV Criteria for Diagnosis of Narrow Personality Disorder
Generalized pattern of instability in interpersonal relationships, mood, and self-image, and marked impulsivity beginning in early adulthood and present in various contexts, as indicated by five or more of the following:

1. Frantic efforts to avoid real or imagined abandonment.
2. Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity alteration: strong and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

No DSM-IV Comments
1. Intense and unstable relationships: Describes the interpersonal manifestations of intrapsychic splitting, which refers to the inability to relate to significant others without idealizing or devaluing.
2. Impulsivity: different from other disorders by its self-injurious nature (substance abuse, bulimic behaviors, etc.). Impulses tend to be replaced by another pattern.
3. Affective instability which could explain the patients’ behaviors. Unlike affective disorders, in BPD it would be more reactive and less durable than in affective disorders.
4. Anger: the source of psychopathology would be excessive aggressiveness due either to excess or to a temperamental child-like response to excessive frustration.
5. Suicidal or self-destructive behaviors: they are a hallmark of borderline patient behavior, although not exclusive to them.
Approximately 75% of patients exhibit self-harm behaviors.
According to Gunderson, self-injurious behaviors are the main reason for referral. These include cutting (80%), hitting (24%), burning (20%), head banging (15%), and biting (7%).
A history of these behaviors doubles the likelihood of suicide.
Suicide often occurs in circumstances that had begun as a gesture.
Markedly increased suicide attempts precede a completed suicide.

ICD-10 Diagnostic Criteria

F60.30 Emotional personality disorder with unstable affect
F60.30 Impulsive type
A. Must meet the general criteria for personality disorders (F60).
B. At least three of the following criteria, one of which must be number (2):

1. Marked predisposition to act unexpectedly and without considering the consequences.
2. Marked susceptibility to rowdy behavior and conflicts with others, especially when impulsive acts are prevented or censored.
3. Proneness to outbursts of anger and violence, with inability to control explosive behavior.
4. Difficulty maintaining lasting activities that do not offer immediate reward.
5. Unstable and capricious mood.

No ICD-10 Diagnostic Criteria
F60.31 Borderline type (borderline)
A. Must meet the general criteria for personality disorders (F60).
B. At least three of the symptoms mentioned above (F60.3), plus at least two of the following:

1. Alterations and doubts about self-image, inner goals, and preferences (including sexual preference).
2. Ability to be involved in intense and unstable relationships, often ending in emotional crisis.
3. Excessive efforts to avoid being abandoned.
4. Repeated threats or acts of self-harm.
5. Chronic feelings of emptiness.

No Multiaxial Diagnosis
Axis I: Allows us to assess the multifaceted symptoms of personality disorders, ranging from simple neurotic to severe psychotic episodes. This will guide drug treatment and psychotherapy.
Axis II: Allows us to define the central, permanent features of the personality as ways of psychic functioning, which will be addressed through individual and family psychotherapy.
Axis III: Intercurrent medical diseases.
Axis IV: We can identify elements that trigger the disease process, which should be considered in all therapeutic instances, as some may be factors that generate repeated stressors and decompensation.
Axis V: We can assess the subject’s functional capacity and self-management; in these disorders, this can be seriously compromised, ranging from slightly decreased to requiring complex care systems.

Borderline Personality

(Variants according to Millon)

Limit Personality

Borderline Personality Disorder: Functional and Structural Domains

Functional Areas

Observed Irregularity: Unusual energy levels with fits of impulsiveness and sudden unexpected changes; sudden and endogenous loss of impulse control and inhibition, constantly endangering emotional activation and balance, and causing recurrent self-mutilating or suicidal behavior.

Interpersonally Paradoxical: Although needing attention and affection, is an unpredictable, manipulative, and fickle opponent, often provoking rejection rather than support. Responds to the frantic fear of abandonment and loneliness with anger and variable self-injury.

Structural Domains

Insecure Self-Image: Experiences confusion of identity, an immature or changing sense of self, often accompanied by feelings of emptiness, seeking redemption for hasty actions and changing self-presentations with expressions of remorse and self-punitive behavior.

Incompatible Object Representations: Internalized representations are rudimentary and untimely, consisting of repeatedly aborted learning, giving rise to conflicting memories, attitudes, needs, emotions, reckless impulses, and conflict-resolution strategies.

Borderline Personality Disorder: Functional and Structural Domains

Functional Areas

Cognitively Erratic: Perceptions and thoughts about what is happening change rapidly, as do conflicting emotions and thoughts about self and others—from love to anger and guilt—resulting in hesitant and contradictory reactions due to their own behavior, creating confusing and conflicting social feedback.

Mechanism of Regression: Under stress, tolerance for anxiety, impulse control, and social adaptation are very primitive from a developmental perspective; among adolescents, immature behaviors are noted, an inability to cope with the demands and conflicts of adult life.

Structural Domains

Divided Organization: Internal structures are divided and conflicting, lacking consistency and coherence. Awareness levels vary, causing rapid shifts across the border separating concerns, memories, and contrary affects. This results in periodic schisms that stagger psychic order and cohesion, causing periodic stress-associated psychotic episodes.

Labile Mood: Fails to adjust mood to external reality; experiences sharp changes from normality to depression or excitement, or goes through periods of depression and apathy interspersed with episodes of intense and inappropriate anger, and brief moments of anxiety or elation.