Borderline (Patient) Personality

Otto F Kernberg, Personality Disorders Institute, New York Presbyterian Hospital, New York, NY, USA;
Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA; and Columbia University Center for
Psychoanalytic Training and Research, New York, NY, USA
Ó 2015 Elsevier Ltd. All rights reserved.

Abstract

This article describes the borderline personality disorder (BPD) as defined in the DSM-IV and DSM-V classification system
and points to the present major shift in the conceptualization of personality disorders. The present, dimensionally oriented
classification of personality disorders stresses the pathology of the self and of the relationship with others as central orga-
nizing concepts regarding the severity of these disorders. Borderline personality organization is described as the structural
intrapsychic organization of experience that explains the pathology of self and object relations characteristic of the BPD. The
clinical differential diagnosis of this disorder, its etiological features, and treatment approaches with psychotherapeutic
methods and psychopharmacological intervention completes this overview.

The borderline personality disorder (BPD) is a prevalent
personality disorder in clinical psychiatric practice; its preva-
lence is approximately 1–2% of the general population, at least
in the advanced English-speaking democracies. It shares with
all personality disorders an enduring pattern of rigid and
maladaptive behaviors and inner experiences that deviate
significantly from cultural norms and lead to significant distress
and/or impairment in patients’ social life, work or profession,
and intimate relations. The Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR) and DSM-5 (to be intro-
duced in 2014) describe the following criteria for the specific
features of the BPD (Table 1).
assessment of the severity of any personality disorder: the
integration or lack of integration of the self, that is, of normal
identity, and the degree of normality or pathology in the rela-
tions of the individual with others (Bender et al., 2011). Here,
what might be called the common sense observation that
patients with personality disorders have difficulty in their
comprehension and management of themselves and with their
comprehension and management of the relationship with
Table 1 DSM-IV and DSM-5 diagnostic criteria for borderline
personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image,

A Major Conceptual Shift
The committee developing the new classification of personality
disorders for the forthcoming DSM-V started from several
assumptions: first, that the DSM-IV classification had proved
unsatisfactory because of the high comorbidity found regarding
the various personality disorders, and the fact that the most
frequent diagnostic conclusion, in clinical practice, was person-
ality disorder NOS, that is, ‘not otherwise specified.’ Second,
within the committee there continued an old dynamic tension
between empirical researchers interested in developing classifi-
cation systems for the personality characteristics of normal
populations, on the one hand, and clinicians who were
concerned about developing a classification system that would
do justice to the personality disorder constellations found in
clinical settings.
The dynamic tension between the researchers interested
in the empirical studies of normal populations, relating them
to the predominant prototypes of personality disorders, and
clinical psychiatry trying to preserve what they saw as their
confirmed experience of the validity of major categories
described in DSM-IV, evolved in the direction of a compromise,
that included an important, major new development, namely,
the agreement on a common basic factor of all personality
disorders, a factor that represented a major criterion for the
and affects marked by impulsivity beginning by early adulthood and
present in a variety of contexts, as indicated by five (or more) of the
following criteria:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not
include suicidal or self-mutilating behavior covered in criterion 5.
2. A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or
sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging,
such as spending, sex, substance abuse, reckless driving, binge
eating. Note: Do not include suicidal or self-mutilating covered in
criterion 5.
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior.
6. Affective instability due to a marked reactivity of mood (for example,
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 (for
example, frequent displays of temper, constant anger, recurrent
physical fights).
9. Transient, stress-related, paranoid ideation, or severe dissociative
symptoms.
Source: American Psychiatric Association, 2013. Diagnostic and Statistical Manual
of Mental Disorders, fifth ed. American Psychiatric Association, Washington, DC,
p. 663.

International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 2 http://dx.doi.org/10.1016/B978-0-08-097086-8.27009-8 755
756 Borderline (Patient) Personality
significant others was recognized, for the first time, as a basic
characteristic of personality disorders. The fact that this dimen-
sion could be explicated, operationalized, and clinically evalu-
ated in terms of the degree of its disturbance satisfied both
empirical dimensionalists, and, particularly, psychodynamic
psychotherapists, who, for over 30 years, have observed,
described, and utilized this dimension in their assessment
and therapeutic approaches to personality-disordered patients
(Kernberg, 1975, 1980).
In summary, the proposed DSM-V personality disorder
model includes two fundamental assessments: criteria A the
general level of personality functioning scale, including the
assessment of self and of interpersonal functioning; and criteria
B the diagnostic criteria for six selected specific categories of
personality disorders.
The assessment of degrees of pathology of the experience of
self includes the following components: (1) Identity: the expe-
rience of oneself as unique, with clear boundaries between self
and others; self-esteem and accuracy of self-appraisal; capacity
for, and ability to regulate the range of emotional experience.
(2) Self-direction: the pursuit of coherent and meaningful short
term and life goals; utilization of constructive and prosocial
internal standards of behavior; ability to self-reflect produc-
tively. The assessment of interpersonal functioning includes:
(1) Empathy: comprehension and application of others’
experiences and motivations; tolerance of different perspec-
tives; understanding of the effects of own behavior on others.
(2) Intimacy: depth and duration of positive connection with
others; desire and capacity for closeness; mutuality of regard re-
flected in interpersonal behavior. In short, the components
proposed to be central to a personality functioning continuum
are identity, self-direction, empathy, and intimacy and the cor-
responding scale differentiates five levels of impairment, going
from nonimpairment (healthy functioning), to extreme
impairment.
The diagnostic criteria for six specific personality disorders
types: antisocial, avoidant, borderline, narcissistic, obsessive
compulsive, and schizotypal, are defined by the level of person-
ality functioning reflected by the self (the A criteria) and by
the corresponding specific pathological personality traits (the
B criteria).
Basic Underlying Structure of the BPD:
Borderline Personality Organization
The term borderline personality organization corresponds to
the common features of lack of integration of the self-concept
and lack of integration of the concepts of significant others
that characterize all severe personality disorders, including
the BPD as a typical expression of this pathology.
‘Borderline personality organization’ is characterized by
pathological identity formation (identity diffusion), primitive
defensive operations, and varying degrees of pathology of inter-
nalized value systems in the setting of maintained but some-
what reduced reality testing marked by a decreased capacity
for subtle and tactful evaluation of interpersonal processes,
particularly in the setting of more intimate relations. This level
of personality organization includes all the severe personality
disorders seen in clinical practice. Typical personality disorders
included here are the BPD, the schizoid, and schizotypal
personality disorders, the paranoid personality disorder, the
hypomanic personality disorder, hypochondriasis (a syndrome
which has many characteristics of a personality disorder
proper), the narcissistic personality disorder (including the
malignant narcissism syndrome (Kernberg, 1992)), and
the antisocial personality disorder. The antisocial personality,
the syndrome of malignant narcissism, and many of the narcis-
sistic personalities are characterized in addition by significant
pathology of internalized value systems (Kernberg, 1989,
1992).
From a clinical standpoint, the syndrome of identity diffu-
sion represents the dominant characteristics of borderline
personality organization and, thus, of the severe personality
disorders as a group, including the BPD. In particular, in the
context of pathological aggression, we see a poorly integrated,
superficial, and unstable sense of self and others, and limited
affect dispositions marked by a combination of intensity and
superficiality in the setting of the predominance of negative
affects. These core features of the severe personality disorders
reflect the splitting or primitive dissociation of an idealized
‘good,’ segment of experience from a ‘bad,’ paranoid one. Split-
ting mechanisms are naturally reinforced by other primitive
defensive operations intimately connected with splitting (projec-
tive identification, denial, primitive idealization, devaluation,
omnipotence, and omnipotent control). This entire constella-
tion of defensive operations serves to distort interpersonal inter-
actions, to create chronic disturbances in interpersonal relations,
and to interfere with the capacity to assess other people’s
behavior and motivations in depth, particularly under the
impact of intense affect activation. The lack of integration of
the concept of the self interferes with a comprehensive integra-
tion of one’s past and present into a capacity to predict one’s
future behavior and decreases the capacity for commitment to
professional goals, personal interests, work and social functions,
and intimate relationships.
The lack of integration of the concept of significant others
interferes with the capacity for realistic assessment of others,
for selecting partners harmonious with the individual’s actual
expectations, and for investment in others. The predominance
of negative affect dispositions leads to an infiltration of sexual
intimacy by excessive aggressive components. The outcome is,
frequently, an exaggerated and chaotic interest in polymor-
phous perverse sexual practices as part of the individual’s sexual
repertoire. In more severe cases, we see a primary inhibition of
the capacity for sensual responsiveness and erotic enjoyment.
Under these latter circumstances, overwhelming negative affect
states eliminate the very capacity for erotic response, leading to
the severe types of sexual inhibition that are to be found in the
most severe personality disorders.
The lack of integration of the concept of self and of signifi-
cant others also interferes with the internalization of the early
layers of the system of internalized values. This leads to a partic-
ularly exaggerated quality of the idealization of positive values
and ideals and to an extremely persecutory quality of prohibi-
tions. These developments lead, in turn, to a predominance of
splitting mechanisms at the level of internalized value systems,
with excessive projection of internalized prohibitions. At the
same time, excessive, idealized demands for perfection further
interfere with the integration of a normal superego.

The BPD and the schizoid personality disorder may be
described as the simplest forms of severe personality disorders.
These disorders reflect identity diffusion in the setting of the
predominance of splitting mechanisms and can be seen as
the ‘purest’ expression of the general characteristics of border-
line personality organization.
Fairbairn (1954) described the schizoid personality as the
prototype of all personality disorders and provided an under-
standing of the psychodynamics of these patients unsurpassed
to this day. He described the splitting operations separating
‘good’ and ‘bad’ internalized object relations, the motivated
self and object representations that comprise the split-off
object relations, the consequent impoverishment of
interpersonal relations, and their replacement by a defensive
hypertrophy of fantasy life. In fact, in the course of
psychoanalytic exploration, the apparent lack of affect
display seen in the schizoid personality turns out to reflect
severe splitting operations; extreme splitting leads to a
fragmentation of affective experience, which ‘empties out’
interpersonal experience. At the same time, the internalized
object relations of the schizoid personality have the split,
persecutory, and idealized characteristics typical of the BPD
(Kernberg, 1975).
The BPD presents structural and dynamic features similar to
those seen in the schizoid personality, but in the borderline
personality we see expression of this pathology predominantly
in impulsive interactions in the interpersonal field (Akhtar,
1992; Stone, 1994). In contrast to the schizoid personality,
where internal object relations are expressed in conscious
fantasy life in the setting of social withdrawal, in the BPD the
same widely split, internalized object relations are enacted in
the interpersonal field. In fact, in the BPD, repetitive, power-
fully motivated interpersonal behaviors often replace
self-awareness. Episodic, intense, overwhelming affect states
(‘affect storms’) and poor impulse control in the setting of
Introverted
Neurotic Obsessive-
personality compulsive Depressive-
organization
High Avoidant
borderline
personality Sado-
organization masochistic
Low
Paranoid
borderline
personality
organization Schizoid
Hypochondriacal
Schizotypal
Psychotic
personality
organization
Figure 1 Summarizes the relationships we have outlined that can be seen among the various personality disorders.
Borderline (Patient) Personality 757
identity diffusion are typical of the BPD, in marked contrast
with the schizoid personality where we see apparent lack of
affect and good impulse control.
It may well be that the descriptive differences between the
schizoid and borderline disorders reflect temperamental differ-
ences. In particular, the borderline and schizoid personalities
appear to differ across the dimension of extroversion and intro-
version, one of the important temperamental factors that
emerges under different names in various models of
classification.
The intensity of affect activation and the lack of affect
control seen in the borderline personality, along with the
high incidence of affective illness that characterizes this group,
suggest the presence of a temperamental factor relating to affect
regulation as a predisposing factor for development of BPD. At
the same time, it is impressive how the degree to which the
integration of negative and positive affect states obtained in
the course of psychodynamic treatments brings about a marked
toning down and modulation of affect response. The increase
of impulse control and affect tolerance in the borderline
personality seen as a result of successful treatment illustrates
that splitting mechanisms play a central role in the pathology
of affects seen in borderline personality (Figure 1).
Differential Diagnosis
The most frequent mistake, in our experience, consists in
confusing the chronic emotional instability and affect storms
of personality-disordered patients with a truly hypomanic or
manic behavior. In the case of manic behavior, the differenti-
ation is easier; here the clear loss of reality testing, the pres-
ence of hallucinations and/or delusions, or inappropriate
social behavior usually leads to intervention by others to
control the patient, interventions that are typical enough to
confirm loss of reality testing and to warrant the diagnosis
Extraverted
Mild
Hysterical severity
masochistic
Dependent Histrionic
Narcissistic
Hypomanic
Borderline
personality
disorder Malignant
narcissism
Antisoclal
Extreme
severity
758 Borderline (Patient) Personality
of a bipolar disorder. Therefore, the confusion between
bipolar illness and BPD is usually reduced to cases of
assumed hypomanic behavior used as the basis to diagnose
bipolar II in patients.
In about 19% of patients with BPD, however, a comorbidity
with bipolar disorder may be present, and the patient shows
both severe, chronic affective instability and clear hypomanic
episodes (Gunderson et al., 2006). To ascertain the presence
or absence of BPD in these cases, it is helpful to evaluate the
general nature of the patient’s relationships with significant
others. Cases of pure bipolar symptomatology do not show
severe pathology of object relations during periods of normal
functioning, and even chronic bipolar patients, who suffer
from both manic episodes and major depressive episodes,
maintain the capacity for relationships in depth, stability in
their relations with others, and the capacity for assessing them-
selves and most significant persons in their life appropriately
(Stone, 2006).
In contrast, in severe personality disorders with the
syndrome of identity diffusion, there is a marked incapacity
to assess others in depth, a lack of integration of the concept
of self, with severe, chronic discrepancies in the assessment of
self and others, and chronic interpersonal conflicts, together
with the difficulty of maintaining stable commitments to
work and profession, as well as to intimate relationships.
The differential diagnosis between an episode of major
depression and a chronic dysthymic reaction in BPD is more
difficult, but eminently feasible if enough time is available to
clarify the four major areas of symptoms.
First are the psychic symptoms of a depressive spectrum of illness.
In major depressions, there is a significant slowdown of the
patient’s thought processes and the patient’s psychomotor
behavior, severe depression of mood that varies between
profound sadness to the total unavailability of any subjective
sense of feeling – a sense of total freezing of all emotional expe-
rience in the most severe cases. Typically, thought processes are
severely self-demeaning and self-accusatory – rather than
focused on accusing and blaming others.
A second area of exploration of the differential diagnosis is the
evaluation of the personality structure that predated the beginning
of the depressed episode. Patients with severe narcissistic person-
ality disorder, BPD, histrionic personality disorder, and maso-
chistic/depressive personality disorder are prone to severe
dysthymic reactions characterized by frequent days with symp-
toms of depression without reaching the intensity, consistency,
and duration of major depressive episodes.
A third area of inquiry facilitating the differential diagnosis
between major depression and characterologically based dysthymic
reactions involves the following neurovegetative symptoms that point
to major depressions: severe insomnia, particularly consistent
early awakening hours before the usual waking time; loss of
appetite with severe weight loss; consistent loss of sexual desire;
possibly impotence in men and suspension of menstrual
periods in women; chronic, severe constipation (considering,
naturally, that this may be secondary to the use of antidepres-
sive medication); a heightened sensitivity to cold temperature;
and, in severe cases, a typical ‘masklike’ facial expression of
severe depression.
A fourth area of diagnostic relevance for the evaluation of depres-
sion is the analysis of environmental triggers that may have preceded
a depressive episode. Typically, in chronic dysthymic, character-
ological reactions, environmental conditions may trigger
depressive reactions, and these environmental conditions are
often remarkably minor, while the patient pays a dispropor-
tionate attention to their symbolic value. Major depressions
usually do not show such a direct relationship between environ-
mental triggers and depression, although the combination of
strong genetic disposition and environmental triggers can occur.
In contrast to this picture in personality disorders, suicide
attempts in the context of symptoms of severe depression are
typical of major depressive disorders and require a careful diag-
nostic assessment of the conditions under which suicidal
behavior occurred. The types of suicidality generally found in
patients with personality disorders that we have just discussed
can most often be treated with outpatient psychotherapy.
One other relatively frequent and often difficult differential
diagnosis is that between a severe personality disorder, particu-
larly a BPD or a narcissistic personality disorder functioning on
an overt borderline level with antisocial features, and an atten-
tion deficit/hyperactivity disorder in adolescent or adult
patients.
Etiology
BPD, in common with all personality disorders, is the outcome
of a complementary series of neurobiological, psychodynamic,
and psychosocial etiological features. While, at this time,
competing theories of personality development and psychopa-
thology would accentuate different features of this series, there
probably is general agreement on the participation of all of
them in determining the final outcome of the crystallization
of a BPD. These features include
l Genetic disposition to abnormal activation of one or several
affect determining neurotransmitter systems, particularly
the dopaminergic, serotonergic, and/or noradrenergic
systems.
l Genetic disposition (related or not to the alternation of
affective neurotransmitter systems), of the structural aspects
and/or functions of the prefrontal cortical control system,
and reactive hyperactivity of the amygdala to negative
stimuli.
l Temperamental hyperreactivity to negative affective stimuli,
related to the genetic dispositions referred to.
l Insecure attachment, related to abnormal caregiver–infant
interaction in the first few months and years of life.
l Exposure to and/or victimization by physical and/or sexual
abuse.
l Severe familial disorganization and unpredictability,
blurring of generational boundaries, and early chaotic
interactions with close family members.
l Strong predominance of the negative segment of intrapsy-
chic experience, in contrast to a weak segment of internal-
ized satisfactory emotional experiences, leading to
persistence and dominance of primitive splitting, and
related defensive mechanisms.
l Fixation, as consequence of all above features, of the
internalized world of object relations and the self at the
pathological organization of identity diffusion, the basic
characteristic of severe personality disorders.

Present day research on the pathology of the neurobiolog-
ical features and the psychopathological constellations of
BPD is attempting to assess their relative importance and inter-
relatedness, their modifications in the course of treatment, and
their implication for the strategies of treatment indications and
techniques.
Treatment
The treatment of the BPD is essentially psychotherapeutic.
There are several specialized psychotherapies available with
evidence-based efficacy, outlined below. Psychopharmacolog-
ical treatment has an auxiliary function and is only indicated
in combination with one of these psychotherapeutic
approaches.
Psychotherapies for this condition may be classified into
psychodynamic and cognitive behavioral treatments.
Psychodynamic psychotherapies Cognitive behavioral psychotherapies
l Supportive psychotherapy l Dialectic behavior therapy (DBT)
(SP) l Schema-focused psychotherapy
l Mentalization-based (SFT)
psychotherapy (MBT) l systems training for emotional
l Transference-focused predictability and problem solving
psychotherapy (TFP) (STEPPS)
Additional treatments include the integrative general psychi-
atric management, and several other approaches with less
empirical research support. Recent comparative meta-analyses
of these treatments – the Cochrane collaboration – conclude:
“There are indications of beneficial effects for both comprehen-
sive psychotherapies as well as non-comprehensive psychother-
apeutic interventions for BPD core pathology and associated
general psychopathology. DBT has been studied most intensely,
followed by MBT, TFP, SFT, and STEPPS. However, none of the
treatments has a very robust evidence base, and there are some
concerns regarding the quality of individual studies. Overall, the
findings support a substantial role for psychotherapy in the
treatment of people with BPD but clearly indicate a need for
replicatory studies.”
From a practical viewpoint, clinical experience indicates that
not all patients respond to all treatments, and selected patient
subgroups may respond to some treatments but not to others.
In general, when the predominant symptoms are circumscribed
to one or several specific problems, such as, suicidal or
para-suicidal attempts, specifically focused emotional crises,
impulsivity or dissociative reactions, cognitive behavioral
approaches, particularly dialectic behavior therapy, would
seem the first treatment of choice. When general life
problems dominate the clinical picture, such as, failure or
breakdown in work or profession, in intimate love relations
or a patient’s social relationships, a psychodynamic approach
may become the first priority. Mentalization-based
psychotherapy focuses on patients’ learning realistic ways to
appreciate their own mental states and the mental states of
significant others, and evinces a broad spectrum of patients
able to benefit from it. Transference-focused psychotherapy is
Borderline (Patient) Personality 759
the only treatment geared to modify the basic pathological
personality structure of BPD patients, and may present the
optimal indication for patients with severe distortion of all
their psychological functions in the areas of work, or
profession, love and sex, and social relations. This approach
is focused directly on the syndrome of identity diffusion, the
basic pathology of the self system and internalized relations
with significant others. At this time, research is proceeding
regarding the process, mechanisms of change, indications and
contraindications of BPD psychotherapies, as well as of the
underlying psychological and neurobiological determinants
of BPD pathology, and patients’ response to treatment.
Regarding psychopharmacologies contributions to the treat-
ment of BPD patients, no one specific medication represents
a treatment of choice. Probably about one-third of patients
respond to medications over a period of months or years. The
main group of medications that have proven helpful to reduce
BPD symptoms include antidepressive medications, particularly
the Selective Serotonin Re-uptake Inhibitors SSRI group; low
doses of atypical antipsychotic medication, particularly risperi-
done, olanzapine, and aripiprazole; and mood stabilizers,
particularly lithium carbonate, valproate, and carbamazepine.
SSRI medication has particular indications for affective dysregu-
lation and impulsive behavioral symptoms. Low dose atypical
antipsychotic medication also targets these same symptoms,
and is particularly indicated for cognitive perceptual symptoms.
Mood stabilizers have a relatively secondary indication for some
patients with affective dysregulation and impulsivity.
See also: Bipolar (Manic-Depressive) Disorder; Cognitive
Behavioral Therapy; Family and Psychiatric Illness: Family
Therapy; Personality Disorders; Women and Psychiatry.
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