Borderline Personality Disorder - From the National Institute of Mental Health (NIMH)

Jim Breiling, Ph.D.
National Institute of Mental Health
6101 Executive Blvd., Room 6-179
Bethesda, MD 20892-9651
(Express or Courier Service: Rockville, MD 20852)
E-mail: jbreilin@mail.nih.gov 
Voice: 301-443-3527
Fax: 301-443-4611

Book Reviews

Diagnosis and Management of Specific Disorders

A Developmental Model of Borderline Personality Disorder: Understanding
Variations in Course and Outcome

By Patricia Hoffman Judd, Ph.D., and Thomas H. McGlashan, M.D. Arlington,
Va., American Psychiatric Publishing, 2003, 231 pp., $38.95 (paper).

MICHAEL H. STONE, M.D.
New York, N.Y.

With the reader's indulgence, I would like to begin this review with my
final comment: this may well be the best book on borderline personality
disorder you are likely to read.

The book is divided into three sections: the first on etiology, the second
on case histories that illustrate variations in course and outcome, and the
third on treatment. The integrated model the authors propose in their first
chapter shows the interaction of genetic and environmental influences that
may combine to create a disorganized pattern of attachment. Impulsivity and
instability of mood may show up as temperament traits stemming in good
measure from the genetic side. On the environmental side are maltreatment by
parents (such as chronic verbal, physical, or sexual abuse) with its
attendant stress and stress from other sources (such as early loss of key
caretakers). All aspects of the mental triad-thought, feeling, and
behavior-are adversely affected, leading to the special types of cognitive
dysfunction, emotional dysregulation, and turbulent behavior that we place
together under the heading of borderline personality disorder. The authors
explain how the abnormally strong emotional reactions in borderline patients
return "more slowly to baseline" (p. 31) and how their common complaint of
"emptiness" is akin to an awareness that "something is missing." This may
reflect a feeling of disconnectedness from others and from the pain they
anticipate from interaction with others: a bad feeling, in other words, that
is protecting the patient from still worse feelings of being overwhelmed by
closeness with others.

The case histories in the second section are taken from the Chestnut Lodge
Long-Term Follow-Up Study that Dr. McGlashan spearheaded in the late 1980s.
The four histories constitute a graduated series from healthiest to most
handicapped. These patients had been in intensive psychodynamic therapy for
many months while at the Lodge, so in that sense they represent recipients
of the kind of treatment that has become a lost art. They came from affluent
families, so they are not "typical" of borderline patients in that respect.
Nor was their treatment typical of what most such patients receive. Their
early histories, however-the malignancy of their homes, the storminess of
their life course, and eventual stabilization at either fairly good function
or at continuing impairment-will be familiar to therapists who devote their
energies to work with borderline patients, no matter what their main
therapeutic schooling or style.

As for the treatment section, there is so much wisdom packed into its two
chapters that I gave up underlining the gems with highlighter lest I
underline the whole 63 pages. Space allows me to mention just a few:

Flexibility and creativity within an ethical and commonsense frame
of reference not only are essential, but make the work challenging and
rewarding. (p. 172)

Work with BPD patients requires a better than average ability to
maintain consistent empathy, since the patient fails in this endeavor toward
himself, the therapist, and important others. (p. 186)

Like the baby's cry, talk of suicide becomes the patient's primary
mode of communicating distress. (p. 204)

Similarly, the borderline patient's impaired emotional regulation
and inability to describe feelings contributes to their overreliance on
behavioral action patterns: they reenact rather than remember. (p. 205)

All relevant aspects of the disorder receive equally succinct and
well-phrased explanations: self-mutilation, moral development and
self-blame, paranoid reactions, dissociation, anxiety over improvement,
secrecy, idealization and devaluation, and primitive defenses such as
splitting.

Although the training and experience of the authors may reflect a largely
psychodynamic tradition, their descriptions and advice will be of great
value to therapists of all approaches and styles. The authors are candid
enough to assert that "work with BPD patients is not for everyone," as they
go on to enumerate some of the qualities in potential therapists that
facilitate this work. One quality that helps, as they mention, is a
"detective-like curiosity." As one who, like Dr. McGlashan, labored long and
hard to trace large numbers of former borderline patients one or two decades
after their discharge from the hospital, I can vouch for that. I hope this
wonderful book of Judd and McGlashan will inspire others to carry on this
work, learning along the way what makes borderline patients behave as they
do, and what we can do to make them better.

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