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Does the ICD 10 classification accurately describe subtypes of borderline

personality disorder?

Article  in  British Journal of Medical Psychology · January 2001

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British Journal of Medical Psychology (2000), 73, 483–494 Printed in Great Britain 483
q 2000 The British Psychological Society

Does the ICD 10 classiŽ cation accurately describe

subtypes of borderline personality disorder?
P. Whew ell,* A. Ryman, D. Bonanno and N. Heather
Newcastle City Health NHS Trust, UK

The aim of the paper is to explore whether the division of borderline personality
disorder, as described in the DSM classiŽcation, into impulsive and borderline subtypes
of emotionally unstable personality disorder in the ICD classiŽcation of personality
disorder, is a valid division. The self-report questionnaire responses of 288 referrals to a
personality disorder service were rated on each of the eight criteria for DSM–III–R
diagnosis of borderline personality disorder. Factor analysis identiŽed two factors; factor
one closely corresponds with the borderline subtype of ICD10, whilst factor two closely
corresponds with the impulsive subtype of ICD10. Criteria common to both factors –
unstable relationships and identity confusion – were considered core features of
borderline personality disorder. The pattern of occurrence of the two factors was similar
to the complex binary picture described by ICD10. However there were also differences.
Firstly, identity confusion is found to be a core feature of both our factors, and this does
not conform to the restriction of identity confusion to the borderline subtypes in
ICD10. Secondly, we found a residual pool of undifferentiated borderline patients and a
small group of pure non-impulsive borderline patients who are not currently accom-
modated within the ICD10 emotionally unstable personality disorder. We conclude
that future classiŽcations of this disorder should accommodate four subtypes, and
suggest these subtypes have implications for treatment and further research.

The term borderline state was Žrst used in 1953 by Knight (1953) to describe a syndrome
which bordered on both psychosis and neurosis. This was a ‘messy’ ill-deŽned syndrome
which seemed as if it might consist of more than one diagnostic entity. A Žrst cluster
analysis of 60 hospitalized patients by Grinker, Werble, and Drye in 1968 delineated four
subtypes: a psychotic border, a core borderline syndrome, an as-if group and a neurotic
border. In an inuential review, Gunderson and Singer (1975) pooled the observations of
numerous previous investigators, describing a discrete borderline personality disorder
with six key criteria. Spitzer, Endicott, and Gibbon (1979) obtained conŽrmation of the
discriminating ability of 17 proposed borderline features from a large number of
American psychiatrists and suggested eight diagnostic criteria for borderline personality
which subsequently became incorporated in DSM–III in 1980 (American Psychiatric
Association, 1980), and which remained largely unchanged in DSM–III–R (American
Psychiatric Association, 1987) as shown in Table 1.
In DSM–IV (American Psychiatric Association, 1994) a ninth diagnostic criteria was
added to the eight of DSM–III–R, namely transient, stress-related paranoid ideation or
*Requests for reprints should be addressed to Dr Peter Whewell, Newcastle City Health NHS Trust, Regional Department
of Psychotherapy, Claremont House, Off Framlington Place, Newcastle upon Tyne NE2 4AA, UK.
484 P. Whewell et al.
Table 1. DSM–III–R borderline personality disorder
A pervasive pattern of instability of mood, interpersonal relationships, and self-image, beginning
by early adulthood and present in a variety of contexts, as indicated by at least Žve of the
following:
1. A pattern of unstable and intense interpersonal relationships, characterized by alternating
between extremes over overidealization and devaluation.
2. Impulsiveness in at least two areas that are potentially self-damaging, e.g., spending, sex,
substance use, shoplifting, reckless driving, binge eating (do not include suicidal or self-
mutilating behaviour covered in (5)).
3. Affective instability: marked shifts from baseline mood to depression, irritability, or anxiety,
usually lasting a few hours and only rarely more than a few days.
4. Inappropriate, intense anger or lack of control of anger, e.g., frequent displays of temper,
constant anger, recurrent physical Žghts.
5. Recurrent suicidal threats, gestures, or behaviour, or self-mutilating behaviour.
6. Marked and persistent identity disturbance manifested by uncertainty about at least two of
the following: self-image, sexual orientation, long-term goals or career choice, type of friends
desired, preferred values.
7. Chronic feelings of emptiness or boredom.
8. Frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-
mutilating behaviour covered in (5)).

severe dissociative symptoms. In a comprehensive review of the present status of

borderline personality Berelowitz and Tarnopolsky (1993) conclude that current
evidence supports the validity of the concept of borderline personality disorder (BPD)
and note that the DSM is a useful instrument which can identify a characteristic
phenomenological core. They also review evidence which suggests that the diagnosis is
stable over time. However, because the DSM–III–R diagnosis of BPD requires at least
Žve positive criteria from eight criteria in total, there are 93 different possible criteria
combinations. There have been continuing suspicions that borderline personality may
not prove to be a homogeneous group and attempts have been made to isolate
subtypes. Using a sample of college students positive for BPD, Rosenberger and
Miller (1989) isolated two factors via factor analysis of diagnostic criteria but found
that the majority of DSM–III–R criteria loaded onto both factors. Rusch, Guastello, and
Mason (1992) analysed retrospective case note DSM–III–R criteria for 89 psychiatric
out-patients and found four underlying factors : a volatility factor, a self-destructive
unpredictability factor, an identity disturbance factor and a fear of abandonment
factor. Blais, Hilsenroth, and Castlebury (1997) conducted a principal component
analysis on 91 personality disorder patients retrospectively rated for borderline char-
acteristics on DSM–IV and obtained three factors : affective instability, unstable relation-
ships and identity disturbance all with across-factor loading, which were thought to be
core characteristics of BPD.
The diagnosis of BPD has been complicated by the development of different criteria for
BPD in ICD10 (WHO, 1992). In ICD10 the main diagnostic category of emotionally
 ICD10 classiŽcation of BPD 485
unstable personality disorder is divided into two subcategories of impulsive personality
and borderline personality in a complex manner so that borderline type must meet the
criteria for impulsive type plus the addition of a number of speciŽc borderline criteria, as
shown in Table 2.

Table 2. ICD10 emotionally unstable personality disorder

Impulsive type
A. The general criteria for personality disorder (F60) must be met.
B. At least three of the following must be present, one of which must be (2):
1. marked tendency to act unexpectedly and without consideration of the consequences;
2. marked tendency to quarrelsome behaviour and to conicts with others, especially when
impulsive acts are thwarted or criticized;
3. liability to outbursts of anger or violence, with an inability to control the resulting behavioural
explosions;
4. difŽculty in maintaining any course of action that offers no immediate reward;
5. unstable and capricious mood.
Borderline type
A. The general criteria for personality disorder (F60) must be met.
B. At least three of the symptoms mentioned in criterion B for F60.30 must be present, with at
least two of the following in addition:
1. disturbances in and uncertainty about self-image, aims and internal preferences (including
sexual);
2. liability to become in involved in intense and unstable relationships, leading to emotional
crises;
3. excessive efforts to avoid abandonment;
4. recurrent threats or acts of self-harm;
5. chronic feelings of emptiness.

ICD10 is now in general psychiatric use in Britain, but the clinical validity of
the subdivision of emotionally unstable personality disorder as a category has not
been explored. In addition we are aware of deŽciencies in previous subtype research in
terms of the small sample sizes used and the lack of British samples. The authors work in
the Regional Department of Psychotherapy, Newcastle in an outpatient team treating
BPD, and have access to an unusually large sample of borderline out-patients. Referrals
to the Borderline Treatment Service are mainly tertiary referrals from consultant
psychiatrists throughout the Northern Region and as such represent the severe end of
the spectrum of BPD. The age range of patients referred is from 18 to 65 years, with
the majority in their 20s and 30s. The service is based upon a core of individual
psychoanalytic psychotherapy, but in addition group treatments and a psycho-educa-
tional brief treatment is also offered. We wanted to explore whether the new categoriza-
tion of emotionally unstable personality disorder, ICD10 and its piggy-back subdivision
into impulsive and borderline subtypes was clinically relevant to our borderline out-
patient population or whether our patients could be better classiŽed within different
subtypes.
486 P. Whewell et al.
Methods
All out-patients referred to the Borderline Treatment Service complete the Screening Test for Comorbid
Personality Disorder (STCPD; Dowson, 1992) as a prerequisiste to entry to the assessment process. This is a
self-report questionnaire derived from the longer Personality Diagnostic Questionnaire (1988) having been
anglicized and validated for British patients (Dowson, 1992) and which screens for borderline, dependent,
histrionic and avoidant personality disorders using DSM–III–R criteria. The questionnaire asks a yes/no
question for each criteria for each of the personality disorders and is thus very simple to score.
For borderline personality there are eight scores corresponding to each of the eight DSM–III–R criteria
which we annotated as follows:

Criterion 1. Unstable interpersonal relations –Unstable relations

Criterion 2. Impulsive behaviour/addictive behaviour –Impulsive/addictive
Criterion 3. Affective instability –Moody
Criterion 4. Angry/violent behaviour –Angry
Criterion 5. Recurrent suicidal behaviour/self-harm –Suicide/self-harm
Criterion 6. Identity confusion –Identity confusion
Criterion 7. Feelings of emptiness or boredom –Empty/bored
Criterion 8. Fear of abandonment –Abandonment fear

STCPD questionnaires received over a 3-year period (from January 1993 to December 1995 inclusive)
were scrutinized.Patients with a diagnosis of BPD (DSM–III–R) as assessed both by an experienced clinician
at interview and a score of 5 or above on the STCPD borderline subscore, representing borderline positive,
were entered into the study. The clinicians were all members of the Borderline Team and trained in the use of
DSM–III–R diagnoses. The borderline section of each patient’s STCPD questionnaire was scored for each of
the eight borderline criteria. This was repeated for all patients together and separately for male and female
subgroups.

Statistical analysis
Patients’ scores on the STCPD were subjected to factor analysis. This refers to a family of statistical
techniques that aims to simplify complex sets of data, usually a matrix formed by the correlations between a
set of variables. The output of a factor analysis is a small number of factors which can be thought of as
dimensions that condense and explain the relationships between the variables. Factors are deŽned by
their loadings which are correlations between a variable and the factor; the higher the loading, the greater
the contribution of the variable in question to the factor. For this reason, greater weight is given to high
loadings, either positive or negative, in interpreting the meaning of factors. A commonly observed rule
is that only loadings greater than or equal to 0.4 should be taken into account in the interpretation of
factors and we follow this rule here. (A clear and accessible guide to factor analysis may be found in
Kline, 1994.)
The type of factor analysis used in the present study was principal components analysis with Varimax
rotation. Principal components analysis is the simplest form of factor analysis in which all the variance in
the correlation matrix is explained and no assumptions are made about variance that may be unique to the
variables or due to measurement error. Rotation of factors is a technique that is used to maximize the
mathematical separation of the factors and render them more easily interpretable. In a Varimax rotation,
the factors are kept orthogonal, i.e., independent in the sense of having zero correlations with each other. An
important decision in the use of any type of factor analysis is how many factors to extract. In this study, we
used a combination of methods—the inspection of eigenvalues, the scree test and an assessment of the
interpretability of factors. The eigenvalue of a factor is a measure of how much of the variance in the data
the factor accounts for and it can thus be used as an indicator of the ‘importance’ of the factor. We followed
the usual procedure of regarding only factors with eigenvalues greater than unity as worth extracting. In the
scree test, a plot is made of the eigenvalues of each successive factor and the point where this plot changes
slope is noted; only those factors before this point is reached are retained for further analysis. The assessment
of the interpretability of factors was concerned with whether the pattern of characteristics suggested by the
factor loadings was clinically meaningful.
 ICD10 classiŽcation of BPD 487
In this study, we carried out three principal components analyses with Varimax rotation on patients’ scores
on the STCPD— one for all patients and separate analyses for male and female patients. A further output
from a factor analysis are factor scores which are scores on a factor for each of the patients in the analysis. A
patient’s factor score can be thought of as the extent to which the dimension of variation described by the
factor applies to him or her. Factor scores can be entered in further types of statistical analysis and in this
study we used t-tests to compare factor scores between groups deŽned by their scores on dependent, histrionic
and avoidant subscales of the STCPD.

Results
A total of 327 questionnaires (212 females, 97 males, 18 not known) were completed
in full. Only 10 questionnaires had to be rejected because the questionnaire was not
fully completed. Of the patients, 288 (184 females, 88 males, 16 not known) had
an STCPD diagnosis of BPD, as well as a clinical diagnosis of BPD as assessed by a
clinician.
Three factors had eigenvalues greater than 1.0. However, scree plot and inspection of
the factors suggested that a two-factor solution was more appropriate (Table 3).

Table 3. Loading for the Žrst two factors extracted from analysis of all borderline patients
(N 288)
Factor one Factor two
a
Unstable relations 0.40 0.44a
Impulsive/addictive 0.62a 0.22
Moody 0.20 0.78a
Angry 0.23 0.65a
Suicide/self-harm 0.53a 0.13
Identity confusion 0.48a 0.45a
Empty/bored 0.29 0.13
Abandonment fear 0.68a 0.25
Eigenvalue 2.0 1.2
Variance 25.2% 14.6%
a
Factor loadings $ 0.4.

Unique loadings
Factor one was loaded with fear of abandonment, impulsive/addictive behaviour and
suicidal behaviour. Factor two was loaded with affective instability and anger/violence.
These two factors accounted for 39.8% of the total variance.

Separate groups by gender

When male and female patients’ questionnaires were analysed separately, four factors had
eigenvalues values greater than one in both groups. However, scree plot and inspection of
the factors suggested that a two-factor solution was more appropriate in both cases. The
Žndings for female patients were similar to those for the whole group, although with
variation in the weight of each item (Table 4).
For male patients factor one loaded with anger, fear of abandonment, difŽculty with
488 P. Whewell et al.
Table 4. Loading for the Žrst two factors extracted from analysis of female borderline patients
(N 184)
Factor 1 Factor 2
a
Unstable relations 0.41 0.50a
Impulsive/addictive 0.67a 0.10
Moody 0.02 0.75a
Angry 0.22 0.74a
Suicide/self-harm 0.45a 0.03
Identity confusion 0.60a 0.33
Empty/bored 0.80 0.14
Abandonment fear 0.69a 0.30
Eigenvalue 2.1 1.2
Variance 26.4% 15%
a
Factor loadings $ 0.4.

interpersonal relationships and self-harming behaviour whilst factor two loaded with
identity confusion with affective disturbance (Table 5).

Table 5. Loading for the Žrst two factors extracted from analysis of male borderline patients
(N 88)
Factor 1 Factor 2
a
Unstable relations 0.57 0.02
Impulsive/addictive 0.61a 0.29
Moody 0.13 0.72a
Angry 0.57a 0.04
Suicide/self-harm 0.54a 0.36
Identity confusion 0.28 0.75a
Empty/bored 0.40a 0.00
Abandonment fear 0.57a 0.39
Eigenvalue 2.0 1.3
Variance 25.1% 16.4%
a
Factor loadings $ 0.4.

Other factors
When a two-factor solution was accepted, emptiness or boredom, which are often seen
clinically as features of BPD/emotionally unstable personality disorder, did not receive a
loading with either of the factors. Consideration of all factors with an eigenvalue greater
than 1.0 resulted, for all patients, in a three-factor solution with emptiness as a single
criterion with a high loading (0.94) for the third factor. The other factors were basically
unchanged although the loadings varied slightly. This solution accounted for 52.7% of
the total variance. In the case of male and female groups, four factors had an eigenvalue
greater than 1.0, but again this solution led to two factors being identiŽed by single
criterion. This reinforced our view that a two-factor solution was most appropriate in
each case.
 ICD10 classiŽcation of BPD 489
Comparison between personality disorder types, DSM III–R
The group was divided into two groups—one that scored positive for dependent
personality disorder and the other negative. They were compared with the two-factor
scores extracted from the analysis. The Žrst group showed a higher mean score on factor
one than the second group (T 4.15; p < .001) but there were no signiŽcant differences
for factor two. The group was again divided into two different groups—one positive for
histrionic personality disorder and the other negative. In this case the Žrst group showed
a higher mean score on both the factors : factor one (T 2.74; p < .007) and factor two
(T 4.07; p < .001). Finally the group was divided into two further groups, one
positive for avoidant personality disorder and the other negative. In this case the group
with avoidant personality disorder showed no signiŽcant difference on both the factors :
factor one (T 1.64; p < .104) and factor two (T 1.01; p < .316) (Table 6).

Table 6. Relation between types of DSM–III– R personality disorders and factor scores derived
from STCPD
Dependent Histrionic Avoidant
Pos. Neg. Pos. Neg. Pos. Neg.
Factor one
Mean 1.44 1.21 1.41 1.23 1.40 1.30
SD 0.50 0.41 0.49 0.43 0.49 0.46
N 194 94 224 64 204 84
(t 4.15; p < .001) (t 2.74; p .007) (t 1.64; p n.s.)
Factor two
Mean 1.74 1.71 1.79 1.51 1.75 1.69
SD 0.45 0.44 0.40 0.50 0.43 0.46
N 194 94 224 64 204 84
(t .52; p n.s.) (t 4.07; p < .001) (t 1.01; p n.s.)

When a frequency analysis was performed, results indicated that of the total
population (N 288), 223 patients scored positively for all the criteria constituting
factor one or for all the criteria constituting factor two: factor one, 106 patients; factor
two, 212 patients; factors one and two, 95 patients. Thus only 11 patients were found
with factor one but without factor two, whereas 117 patients had factor two but not
factor one. The remaining 65 had different combinations of symptom criteria, not adding
up to constitute either factor one or two (Figure 1).

Discussion
Factor one for all patients has exclusive loading for impulsive/addictive behaviour,
suicidal/self-harm behaviour and fear of abandonment. The highest loading was fear of
abandonment (criterion eight). Abandonment in borderline patients causes internal
turmoil and tension whilst the avoidance of separation from important others exerts a
calming effect. The search for calmness, and a concomitant decrease in internal turmoil, is
the basis of many addictive, impulsive behaviours (criterion two). Similarly self-harm
behaviours (criterion Žve) are often used by borderline patients as self-soothing devices to
490 P. Whewell et al.

Figure 1. Emotionally unstable personality disorder (ICD10) compared with factor one and factor two.

reduce inner tension, whilst death is commonly seen by the borderline patient as a calm,
peaceful state in contrast with the turbulence of current life. Because factor one seems to
be concerned with internalizing a soothing experience in order to calm internal turmoil
we decided to call it the calm-internalizing factor.
Factor two for all patients has exclusive loading for moody and angry (criteria three and
four). This factor implies direct expression of feelings as a way of externalizing inner
turmoil and so we decided to call factor two the mood-externalizing factor.
Unstable interpersonal relations (criterion one) and identity confusion (criterion six)
loaded onto both factors; our Žndings suggest that the core features of BPD are therefore
identity confusion and unstable interpersonal relations representing internal turmoil.
The two identiŽed factors, the calmness-internalizing factor and the mood-externalizing
factor can be construed as habitual defensive patterns against this internal turmoil, one
defence seeking calmness, one defence involving externalization of the emotional turbulence.
Differences between factor one and factor two in terms of associations with comorbid
personality disorders also delineated by the STCPD histrionic, dependent and avoidant
personalities, were of interest. Factor one was associated with dependent personality,
which may be explained because of the high loading of abandonment fear onto factor one.
The absence of loading of dependent personality with factor two may mean that patients
who use a mood-externalizing defence are not anxious about rejection. It was of interest to
Žnd that histrionic personality was associated with both factor one and factor two. Thus
the mood-externalizing factor two seems not to be a function of histrionic inter-personal
relating.
When female patients were examined (see Table 4) the results were very similar for all
patients, the only difference being that identity confusion loaded exclusively onto factor
 ICD10 classiŽcation of BPD 491
one. This seems to indicate that the use of mood-externalizing factor two, was for women
associated with a greater sense of self-identity than the use of the calmness-internalizing
factor one.
When male patients were examined (see Table 5) there was a different picture with
angry and moody criteria separating so that factor two had now only two exclusive
loadings, moody (criterion three) and identity confusion (criterion six). This implies that
men discharge anger as part of a calm-internalizing defence and that anger in this case is
not primarily a communication of mood disturbance. Men who were emotionally
expressive of mood were more likely to be uncertain of their identity, implying that
emotional expressiveness in men is not compatible with a stable sense of male self in
borderline patients.
It is possible to speculate therefore that men and women borderline patients differ
in their use of anger. It seems that men use anger as discharge, to augment an
internal sense of self-calm, whilst women use anger as a communication to the other
person, hoping to disturb the other person. Women who are being angry/moody are more
sure of their identity, whilst men who are expressing moodiness are less certain of their
identity.
Our two factors, the calm-internalizing factor and the mood-externalization factor
are based upon the phenomenology of the eight DSM–III–R criteria, but seem to
bear a strong resemblance to psychic defence mechanisms as described in psycho-
analytic literature. Factor two, mood-externalizing defence, has similarities with one of
the ways in which Freud used the concept of projection in terms of the externalization
of conict (Freud, 1916). Factor one, calm-internalizing factor, has similarities
with introjection, a term Žrst described by Ferenczi (1909). Ferenczi pointed out
the link between oral impulses and introjection, and between anal impulses and
projection.
When our results are compared with ICD10 (see Table 7), it is clear that there are
similarities between the impulsive subtype of emotionally unstable personality disorder
and factor two in that both share three criteria: unstable relations, moodiness and angry
behaviour. However, there is a difference in that impulsive/addictive behaviours are
associated in our Žndings with factor one. This leads us to conclude that the ICD10
impulsive subtype is wrongly named. Secondly, the Borderline Subtypes of ICD10 bear
close correlation with a combination of our factor one and factor two.

Table 7. Emotionally unstable personality disorder (ICD10) compared with factor one and factor
two
Impulsive type Factor two Borderline type Factor one
Unstable relations * * * *
Impulsive/addictive * * *
Moody * * *
Angry * * *
Suicide/self-harm * *
Identity confusion * * *
Empty/bored *
Abandonment fear * *
492 P. Whewell et al.
There are similarities and differences between our factor analysis of DSM borderline
personality and the complex binary classiŽcation of ICD10 emotionally unstable
personality disorder.
The similarities are the high numbers of patients exhibiting mood-externalizing
factor only (117/288) representing the impulsive type ICD10, plus the large
number of combined factor one and factor two patients (95/288) representing the
borderline type ICD10. In all, these similarities account for the majority of the patients
researched (212/288). However, there were also differences between our factor analysis
and ICD10.
Firstly, we have identiŽed a very small number of patients (11/288) who are calm-
internalizing types only which in terms of ICD nomenclature would be pure borderline
but without impulsive characteristics. There is no speciŽc category for this group in
ICD10. These 11 patients may represent the subcategory of borderline patients originally
described by the psychoanalyst Helen Deutsch (1942) as ‘as-if’ characters, who, lacking a
solid self, adhere to others to conceal internal deadness, and react very badly to separation.
In more recent borderline psychoanalytic literature Sherwood and Cohen (1994) have
termed these patients ‘quiet borderlines’.
As described in the introduction to this paper the referrals to our Borderline Service,
from whom the sample was derived, are predominantly tertiary referrals from psychiatric
services and as such are likely to be predominantly ‘noisy borderlines’. We would expect a
community survey, or a survey of borderline personality in primary care to reveal a much
larger proportion of quiet borderline patients, and further research in these areas is
suggested.
Secondly, there is a group of borderlines (65/288) who score as borderline by DSM
but do not possess factor one or factor two loadings. We have described these as
undifferentiated borderlines and again they are not represented by the ICD10
categorization.
Our results are similar in some respects to the Žndings of Blais et al. (1997) who by
factor analysis found three factors, the Žrst consisting of emptiness, fear of abandonment
and identity disturbance; the second consisting of anger, paranoia and affective instability
(moodiness); the third consisting of impulsivity, suicidality, unstable interpersonal
relations and affective instability. Factor two of Blais et al. is similar to our own factor
two, whilst our factor one conforms approximately to the combined factors one and three
of Blais et al. The sample used by Blais et al. was small, 91 patients with personality
disorder, compared with our own sample of 288. Rusch et al. (1992) found four factors
they called (one) volatility, (two) self-destructive unpredictability, (three) identity
disturbance and (four) abandonment fear.
They go on to suggest four types of borderline: an unstable type (factors one and two),
an identity disturbance type (factors two and three), a severe type (factors one, two and
three) and an undifferentiated type (factor two). There are similarities with our
delineation of four borderline types: pure calm-internalizing, pure mood-externalizing,
combined and undifferentiated.
Currently there is discussion in the international scientiŽc community about the
classiŽcation of borderline personality disorder for DSM–V. Also there is a groundswell of
dissatisfaction with the name borderline itself.
We suggest that the emotionally unstable personality disorder is a more acceptable
 ICD10 classiŽcation of BPD 493
term for patients, and our research suggests four subtypes we would call subtypes I, II, III
and IV as follows :
Subtype I – Combined factor one and two
Subtype II – Factor two only
Subtype III – Factor one only
Subtype IV – Undifferentiated

We feel that this classiŽcation does have important potential implications for
treatment. In our service we are attempting to introduce cost-effective brief treatments,
particularly a psycho-educational group treatment. However, brief treatments are well
known not to be easily tolerated by some borderline patients because of abandonment
fears. Such patients are described by our factor one, present in subtypes I and III and these
subtypes may need longer therapies. However, patients characterized only by factor two,
and a lack of factor one, i.e. subtypes II and IV may be able to tolerate brief treatments
speciŽcally focused on their defensive style. Research linking subtypes to outcome of
treatment is thus indicated.

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Received 16 April 1999; revised version received 21 December 1999

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