Developing conceptualization of borderline personality disorder
Borderline Personality Disorder
Social Control, Informal
The definition of personality disorder has evolved from agrowing clinical consensus to official status in the DSM diagnosticsystem since DSM-III. The definition proposed for DSM-5 highlightsimpairments in self and interpersonal functioning and thepresence of pathological personality traits. There remains a cleartension in this definition. Researchers prefer traits that can be measureddimensionally, and clinicians prefer description of functionalprocesses. Furthermore, the definition implies that personality disorderfunctioning is relatively stable over time, but the issue of whatis stable and what is changing about personality and personalitydysfunction remains an important area of research investigation.This review of the evolution of our understanding of BPDsuggests significant advance since the 1970s. As we have seen, clinicalexperience with these patients in the 1970s lead to a phenomenologicalapproach that informed the criteria in DSM-III and aphenomenological/structural approach that posits an internal psychological organization that guides behavior. Ecological momentary assessment and social neurocognitive science are bringing advanced technology to how patients with BPD function in the present, progressing from attention to certain incoming stimuli, appraisal of these stimuli, and cognitive-affect and behavioral reactions. This sequence of functioning is disturbed in patients with BPD in particular ways. With greater precision in detecting the interpersonal behavior of patients with BPD through ecological momentary assessment and the use of fMRI to detect the operation of underlying neurocognitive structures, the field is approaching an integration of the phenomenological approach of Gunderson and the structural approach of Kernberg. This review suggests that methodological advances have helped take us beyond a purely phenomenological approach to an understanding that personality disorder is an emergent end product of interacting processes, with neurobehavioral systems underpinning the psychological organization and behavior at another level of the organism. From this point of view, BPD may be seen as a dysregulated, reflexive response to managing the rejection/trust dilemma in interpersonal situations. Patients with BPD are constantly faced with an approach/avoidance dilemma in which they desperately want to connect with others while being intensely threatened by the prospect of rejection. However, they may show different types of maladaptive solutions to deal with this dilemma, resulting in different phenomenological subtypes. With the approaching arrival of DSM-5, which will have no changes in the criteria for the personality disorders, and the contrasting RDoC approach of the NIMH, it remains to be seen how these two divergent approaches can clearly take us from the research laboratory to clinical practice. There is a real danger that the clinical world and the research world will proceed in somewhat different directions. With the growing understanding of the behavioral repertoire and the underlying neurobehavioral organization in borderline pathology, it may enable us to more carefully define the changing characteristics of patients with BPD and those elements that are more consistent and stable over time. With these advances, it is possible that future treatment development will be guided less by theory (i.e.,cognitive behavioral, schema, psychodynamic) but more by the empirical understanding of the sequence of cognitive-affective reactions that disturb interpersonal functioning in patients with BPD. Copyright © 2013 by Lippincott Williams &Wilkins.
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