borderline personality disorder

5/19/2018 Borderline Personality Disorder

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Borderline Personality Disorder


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Contents

Abstract ................................................................................................................................. 4

History of borderline personality disorder ............................................................................ 5

Characteristics of borderline patients .................................................................................... 7

Etiology ................................................................................................................................. 8

Psychodynamic approach .................................................................................................. 8

Cognitive-social theories ................................................................................................. 10

Genetic and biological factors ......................................................................................... 10

Environmental factors ..................................................................................................... 11

Stress diathesis model ..................................................................................................... 11

Borderline personality disorders and other psychological disorders .................................. 12

Borderline and Posttraumatic stress disorder .................................................................. 12

Borderline and antisocial personality disorder ................................................................ 12

Impulsivity .................................................................................................................. 12

Affective instability ..................................................................................................... 13

Cognitive symptoms .................................................................................................... 13


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Psychotherapeutic treatment ............................................................................................... 14

Cognitive-behavioural treatment ..................................................................................... 14

Psychodynamic therapy .................................................................................................. 15

Borderline personality disorder across cultures .................................................................. 16

Conclusion ........................................................................................................................... 17

References ........................................................................................................................... 19


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Abstract

Criteria for diagnosing borderline personality disorders have been changing ever since the

term has been introduced in psychological theory and practice. It is often discussed its

relation to other personality disorders as well as its etiology. As the prevalence of this

disorder grew bigger, the need for deeper understanding the phenomenology, etiology and

implications for treatment of borderline personality disorder emerged. Dominant explanations

of the nature of borderline personality disorder originated from psychodynamic theories

which emphasized early development as an essential factor for the development of this

disorder. Other theories and perspectives on the causes of borderline personality disorder

have emerged, but there is still a question of effective treatment of this disorder. On the other

hand, there has been growing interest of researching borderline personality concept in

different cultures and validating the results of American and European studies on Eastern

cultures. This paper had the goal to present the development of the concept of borderline

personality disorder, to determine its characteristics in terms of diagnosis and

phenomenology, to give perspective on its causes and treatment and to present findings of

studies in Asia regarding borderline personality disorders.


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History of borderline personality disorder

The history of personality categorization can be traced to the early Greeks and character

writing originating in Athens. These depictions of characters were sketches that described

common types of characters, emphasising a dominant trait as a way of explaining a flaw or

foible of an individual. In 4thcentury B. C., Hippocrates identified four basic temperaments

associating each with the dominant body fluid. Centuries later, Galen associated

Hippocratess choleric temperament with a tendency towards irascibility, sanguine

temperament with optimism, melancholic with sadness and phlegmatic temperament with

apathetic disposition (Millon & Davis, 1995).

In 18thcentury, Gall argued that intensity and character of thoughts and emotion correlate

with variations in the size and shape of the brain or its encasement, the cranium. Pinel

observed patients who engaged in impulsive and self-damaging acts although their reasoning

abilities were unimpaired. He referred to it as la folie raisonnante. He described cases of

insanity without delirium and was the first to recognize that madness does not signify the

presence of a deficit in reasoning powers. Rush depicted individuals with lucidity of thoughts

and socially deranged behaviours. (Millon & Davis, 1995).

In early 20th century, people with personality disorders were viewed as, as Scneider

described them, a set of psychopathic personalities which co-occurred with other psychiatric

disorders (Oldham, 2009). Kraepelin formulated a number of subaffective personality

conditions, similar to current borderline personality disorder; those included excitable

personality, mixture of fundamental states, extraordinarily great fluctuations in emotional

equilibrium; they are easily moved by their experiences, their mood is a subject to frequent

change, give expression to thoughts of suicide; they are mostly very distractible and unsteady

in their endeavours, they make sudden resolves and carry them out on the spot, run off

abruptly, go abruptly, enter a cloister (Kraepelin, 1921, pp. 130-131, in Krawitz & Jackson,

2008).

The term borderline personality disorder was first introduced in 1930s by Adolph Stern

(1938, in Gunderson & Links, 2008) in order to identify groups of clients who did not fit into

usual categorization at the time. People were diagnosed as either neurotic, involving what we

now refer to as anxiety and depressive disorders, or psychotic, involving bipolar disorder and

schizophrenia, as we now refer them. In spite of the dominant categories of neurotic and


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psychotic symptoms, clinicians recognized many patients suffering from severe emotional

distress or experiencing social or occupational impairment due to the symptoms they

experienced. Their pathology did not involve frank psychosis or other syndromes

characterized with depressive episodes, persistent anxiety or dementia (Oldham, 2009).

Patients from this uncategorized group expressed symptoms of neurotic category, but did not

respond to the usual treatment of neurotic disorders at the time. They had occasional

psychotic or psychotic-like experiences, but they were not sufficient to categorize them into

psychotic category. Patients with most severe and disabling symptoms were referred to long-

term inpatient treatment or outpatient psychoanalysis or psychoanalytically oriented

psychotherapy (Oldham, 2009).

From the context of World War II the need for standardized psychiatric diagnosis

emerged. War department developed a document labelled Technical Bulletin 203,

representing a psychoanalytically oriented system of terminology for classifying mental

illness precipitated by stress. Together with APA experts, diagnostic manual for psychiatric

diagnoses was developed. (Oldham, 2009). It was the framework for the first edition of DSM.

DSM I presented a general view on personality disorders which persisted to the presence.

Personality behaviours were viewed as more or less permanent patterns of behaviour and

human interaction, established b early adulthood and unlikely to change throughout the life

cycle (Oldham, 2009, p. 6).

Borderline personality disorder first appeared in DSM III manual in 1980s, together with

narcissistic personality disorder. The criteria for defining borderline personality disorder

emphasised emotional dysregulation, unstable interpersonal relationships and loss of

impulse control more than cognitive distortions and marginal reality testing, which were

more characteristic of schizotypal personality disorder (Oldham, 2009, p. 8). Grinker et al.

(1968, in Gunderson & Links, 2008, p. 3) argued that borderline psychopathology is a by

product of social changes during the twentieth century. The earlier burdens of manual labour

and the earlier restrictions of travel, communication and leisure time may have offered the

structure, survival activities, and monitors that silently kept such psychopathology in check.

DSM IV finally defined nine criteria for borderline personality disorder diagnosis. They

include: a) disturbed relationships; 2) abandonment fears; 3) chronic feelings of emptiness; 4)

affective instability; 5) inappropriate, intense anger or lack of control of anger; 6) impulsivity

in at least two potential self-damaging activities; 7) suicidal or self-mutilating behaviour; 8)


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identity disturbance; 9) transient, stress related paranoid ideation or severe dissociation

symptoms (Gunderson & Links, 2008).

There is a growing debate about the appropriateness of use of categorical or dimensional

system of classifications, relevant criteria for diagnosing it and its association to other

personality disorders.

Characteristics of borderline patients

Borderline patients lack of self-soothing capacities derived from the ability of a child to

internalize nurturing caregivers and sooth themselves even when the caregivers are not

present. Lack of those abilities creates a tendency of evoking intense feelings of lonelinessand panic through the life of borderline individual.

Herman (1997, in Braid, 2008) describes the relationships of individuals who survived

severe childhood abuse. These relationships involve intense periods of searching for intimacy

and idealization of the other person, alternating with periods of angry withdrawal and

denigration. They are driven by the need for care and fear of abandonment and betrail. When

disappointed, they furiously denigrate the person they idealized and adored. Even minor

disappointments tend to evoke childhood experiences of neglect and cruelty (Braid, 2008).

The lack of evocative memory, the ability to recall memories of comforting and secure love

relationship leaves them dependent on real care and assurance from others. The experience of

abandonment can become so intense that the patient feels that they cannot survive without the

relationship (Judd & McGlashan, 2008).

Characteristic assumptions of borderline patients involve the idea that people are

dangerous and malignant figures, the idea of them being powerless and vulnerable and theidea that they are inherently bad and unacceptable to both self and others. Following these

ideas, patient does not dare to trust others, and themselves cannot be trusted either (Arntz,

1993)..

Borderline patients are obsessed with the potential rejection or abandonment; they are in

need to be with others in order to be able to perceive themselves. They use others as mirrors

of their self-perception (Dobbert, 2007, p. 66). Persons afflicted with borderline personality

disorder are prone to perceive relationships with others as intimate very early. Their


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relationships are unstable due to borderliners delusional beliefs of enduring love or

friendship which ends as soon as their expectations are not fulfilled. Borderline personality

disorder is characterized with identity disturbances which might be expressed through radical

changes in styles of dressing, attitudes, social preferences and hobbies (Dobbert, 2007). Their

thinking style is, one-dimensional and childish, and the evaluations black-and-white due to

undeveloped cognitive powers (Arntz, 1993). When borderline individuals feel deprived or

betrayed they experience anger and anxiety that activate coercive and controlling attachment

behaviours (Judd & McGlashan, 2008, p. 189). They employ splitting mechanisms during

these states which prevent them composing opposite feelings and thoughts about the other

person.

Etiology

Psychodynamic approach

Psychoanalytic theories were the first to generate a concept of personality disorder.

Personality disorders began to draw attention of psychoanalysis because of their resistance to

psychoanalytic treatment and explanation methods. Freuds view on psychological problems

in terms of conflict and defence mechanisms was not suitable enough to explain the origin of

personality disorders and most analytic theorists have turned to ego psychology.

Ego psychologists describe personality disorders as states of various deficits in

functioning, such as poor impulse control and affect regulation and deficits in the capacity for

self-reflection. Stern (1938, in Porder, 1993) suggested that failures in early mothering are

related to the pathological narcissism of the borderline individual, providing a soil for the

other pathology to emerge. Disturbances in early childhood are causes of anxiety, idealisation

tendencies and childlike self-image. He described features of borderline personality disorders

which involved narcissism created as a self-perserving function, leading to psychotic-like

transference, lack of maternal affection, parental quarrels, outbursts direct at child, early

divorce, separation or desertion, cruelty, brutality and neglect by parents over many years

duration (Baird, 2008). Greenacre (1971, in Porder, 1993) argued that trauma in the first two

years of life could have interfered with ego development. Mahler and Furer (1968) suggested

that there was a period of vulnerability in early childhood the separation-individuation

phase; disturbances in this period could be related to borderline phenomena. Mothers


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resistance towards individuation created pathological regressive bond between borderline

individuals and their mothers (Porder, 1993).

Otto Kernberg (1975a, 1984, 1996, in Heim & Western, 2009) developed a theory of

personality organisation in which he proposed a continuum from chronically psychotic levels

of functioning, through borderline functioning as severe personality disorders, through

neurotic to normal functioning. What distinguishes individuals with borderline disorders from

the ones with neurotic disorders is their regulation of emotions through immature, reality-

distorting defences such as denial and projection (primitive defences), and their difficulties

in forming mature multifaceted representations of themselves and significant others (identity

diffusion)(Heim & Western, 2009).

Developmentalists suggest that borderline pathology is a result of defect in development

of early object relations. Internalization of hostile, abusive, critical, inconsistent or neglectful

parents creates children vulnerable to fears of abandonment, self-hatred and tendency to treat

themselves as their parents treated them (Heim & Western, 2009). Winnicott (1953/1958,

1960/1965) developed concepts which contributed in later treatment of borderline patients.

These concepts include transitional objects and transitional phenomena and the holding

environment. Transitional object and transitional phenomena concept refers to the childsability to imagine me/not me. This concept had implications on relation between patient

and therapist and it is considered that it represents a developmental basis for the ability of the

patient to use transference during therapy. The holding environment represents a safe and

protected place where the child can be alone or alone with others, a space that usually good

mother provides (Porder, 1993).

Developmentalists consider that borderline occurs early in childhood, starting with

extreme anxiety and primitive defences that protect the integrity of ego. Object relationships

are immature and incapable of maintaining stable sense of self or identity. The border

between self and the outside world is blurry and the perception of reality damaged (Porder,

1993).

There is a high correlation between the level of borderline psychopathology and the

severity of childhood trauma (Baird, 2008).


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Cognitive-social theories

Cognitive-social theorists believe that learning is the basis of personality and that

personality dispositions are shaped by their consequences. Environmental influences and

individuals information processing about self and world are the basis for building personality

(Heim & Western, 2009).

Personality disorders are interpreted in light of the schemas, expectancies, goals, skills,

competencies and self-regulation. Dysfunctional schemas lead patients with personality

disorders to misinterpreting information, encoding information in biased ways or view

themselves as bad or incompetent. Borderline patients are prone to misinterpreting peoples

intentions and have troubles with self-regulation, including specific skills. According to

Linehan, emotion dysregulation is the essential feature of borderline personality disorder.

Emotion dysregulation include difficulties in a) inhibiting inappropriate behaviour related to

intense affect, b) organizing oneself to meet behavioural goals, 3) regulating physiological

arousal associated with intense emotional arousal and 4) refocusing attention when

emotionally stimulated. These difficulties lead to disturbances in interpersonal relationships

and in developing stable sense of identity (Heim & Western, 2009).

Genetic and biological factors

Past two decades, genetic disposition for borderline personality disorder has been studied.

In one twin study, the heritability of 0.69 for borderline personality disorder was found and

overall heritability of 0.60 for DSM IV Cluster B personality disorders. The heredity of the

disorder expresses itself through traits of affective instability, impulsivity, self-harm andidentity problems. Case histories also provide evidence of presence of Cluster B disorders

and traits in patients families(Judd & McGlashan, 2008).

Andrulonis et al. (1980, in Judd & McGlashan, 2008) found wide range of problems with

brain functioning in borderline patients, including episodic dyscontrol, neurological

dysfunction, epilepsy, minimal brain dysfunction and learning disabilities. Study of Kimble et

al. (1997, in Judd & McGlashan, 2008, p. 9) found neurological vulnerability of borderline


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patients in 87,5% , with a high occurrence of childhood speech/language disturbance,

learning disabilities, ADHD and reported complications of birth and pregnancy.

Affect and impulse dysregulation are attributed to altered functioning of central

serotonergic system, while suicide and self-injurious behaviour are attributed to lower levels

of 5-HT and abnormalities in dopaminergic system. These behaviour patterns were

established to correlate with severe traumatic stress in childhood, such as physical and sexual

abuse (Judd & McGlashan, 2008).

Environmental factors

There is an increase in prevalence of parasuicide and completed suicide in youth

diagnosed with borderline personality disorder. This fact could be interpreted by the

breakdown in traditional structures which guides the development of young people.

Impulsive disorders such as borderline, are particularly responsive to social context and the

structure and limits it provides. Traditional societies are defined as having high social

cohesion, fixed social roles and high interpersonal continuity which provide framework for

building sense of identity and the feeling of belonging (Paris, 2007). Individuals with

borderline personality disorders act impulsively as a way to handle their emotional

dysregulation. Linehan (1993, Paris, 2007) suggested that impulsive behaviours decrease in

patients with borderline personality disorder in the conditions with social support.

Stress diathesis model

In stress diathesis model, every category of mental disorder is associated with certain

genetic vulnerability. Genes shape individuals vulnerability, temperament and traits. Traits

become maladaptive in certain environmental conditions, meaning that diathesis becomesapparent when uncovered by stressors. The interaction between diathesis and stressors is

bidirectional: genetic predispositions determine the way people react on the stimuli in their

environment, while the stressors and environmental factors in general determine what genetic

dispositions would be uncovered


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Borderline personality disorders and other psychological disorders

Borderline and post-traumatic stress disorder

It is often discussed whether borderline personality disorder and post-traumatic stress

disorder are synonymous because of the central role of the trauma in their development.

These disorders often occur together and have similar symptoms. However, there are certain

distinctions. Individuals with PTSD have relatively accurate memories of the traumatic event,

while borderline individuals have experienced trauma in early age when such memories

might have not survived. Trauma in early childhood may induce symptoms similar to those in

PTSD. However, these symptoms become transformed and incorporated into the personality

structure because of the childs inability to process and integrate information (Judd &

McGlashan, 2008).

Borderline and antisocial personality disorder

Applying cluster analysis to the symptoms of borderline personality disorder, Hurt et al.

(Paris, 1997) found three underlying dimensions: impulsivity, affective instability and

cognitive deficits. Livesley and Schroeder (Paris, 1997) also found the same three dimensions

including the fourth: identity diffusion.

Impulsivity

There is a significant overlap between impulsivity of patients with borderline and

antisocial personality disorder. Borderline individuals sometimes demonstrate petty theft,

substance abuse, dangerous driving or high risk sexual activities as primitive defences from

the intense feelings of anxiety. Those characteristics are defining features of antisocial

personality disorder. However, impulsivity has different background within these disorders.

Antisocial patients use people and discard them after they no longer need them, while

borderline patients tend to discard others after, as they perceive it, being betrayed and

disappointed by them. Antisocial patients exploit others, while borderline patients tend to be

exploited. Antisocial patients lack of concern for their victims, while borderline patients are

likely to comply with others (Paris, 1997).


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Affective instability

Borderline patients suffer from continuous dysphoria which makes them highly responsive

to their environment. They use impulsive actions as distraction from dysphoric emotions.

Antisocial patients express dysphoric mood when they are prevented from acting out (Paris,

1997). Both antisocial and borderline patients seem to use their maladaptive behavioural

patterns to avoid dysphoric emotions.

Cognitive symptoms

Borderline and antisocial personality disorder differ in symptoms that involve auditory

hallucinations, subdelusional paranoid trends, mycropsychoses or chronic depersonalization

and derealisation experiences. Although not systematically studied on antisocial patients, it is

considered that these symptoms are used to help them escape from criminal charges (Paris,

1997).

According to Paris (2000) gender influence provides the explanation of differences

between types of personality disorders from cluster B. Borderline and antisocial disorderhave common family histories and impulsivity as phenomenological distinction. Paris argues

that both borderline and antisocial disorder could represent alternate versions of the same trait

pathology with symptoms specific to gender (Paris, 2000, p. 79). Exploitive behaviour and

aggressivity typical for antisocial disorder is more common in men, while the aggression

against self and self-destructive behaviour typical for borderline patients is more common in

women. Patients in child psychiatric are usually boys, mainly because of their behavioural

disruptions that lead to referral. Paris argues that is likely that girls experience the same

intensity of distress, but tend to develop more internalizing then externalizing symptoms.

Boys are more likely to develop antisocial behaviour at earlier age, while girls are more likely

to develop borderline personality disorder later in life, which would explain the dominance of

male patients on child psychiatric. Both boys and girls have history of conduct disorder

during childhood (Paris, 2000).


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Psychotherapeutic treatment

Cognitive-behavioural treatment

Perhaps the most difficult thing in treating borderline patients is constructing a working

relationship. The contact between the patient and the therapist is dominated by ambivalent

feelings, including a desire for help and acceptance in one hand and the feeling of being hurt

and rejected. Therefore, it is hard to determine and follow the goals and methods of the

therapy. The patients inability to trust others can create severe difficulties for the therapy

process. The therapist might feel discouraged, but they need to realize that the patients

behaviour is the reflection of their problem. Trust cannot be enforced by discussion or

convincing the patient; empathetic reation to the problem, consistent and congruent behaviour

are crucial in developing trusting relationship (Arntz, 1993).

Emphasis in cognitive-behavioural therapy is on banishing symptoms or making them

more bearable. In long-term, the goal is to cope with emotions more adequately, modify

thinking errors, and in the end, to process trauma and change their core schemas. Modifying

thinking patterns can be accomplished by introducing standard cognitive techniques, such as

cognitive diary. Socratic questioning can be used for deriving information and moving the

patient to the desired goal, but without triggering intense emotional responses before the

patient is ready (Fusco & Apsche, 2005). Changing core schemas and processing trauma

cannot be done easily. Therapist needs to clarify the context of the trauma and to approach

patients memories and emotions slowly, with caution in order to help the patient to release

their fears and at the same time maintain the control over their experiences (Arntz, 1993).

Layden et al. (1993, in Fusco & Apsche, 2005) described characteristic maladaptive

schema in borderline patients involving dependence, lack of individuation, emotional

deprivation, abandonment, mistrust, unlovability and incompetence. These schemas produce

cognitive distortions such as dichotomous thinking and catastrophizing and lead to significant

dysfunction of the patient. Techniques such as Cognitive conceptualization diagram and the

Incident chart are used for identifying schemas and organizing their impact on patients

functioning (Fusco & Apsche, 2005).


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Psychodynamic therapy

When treating patients with borderline personality disorder, therapists deal with the

challenge of handling patients struggle with interpersonal closeness and resistance which

might be expressed through acting out, intense negative affects and regressive and self-

destructive behaviours (Waldinger & Gunderson, 1989). It is necessary to identify self-

destructive nature of patients maladaptive behaviour and to confront the patient with the fact

that self-destructive behaviour is their way of dealing with intense and intolerable affects.

According to Kerneberg (Waldinger & Gunderson, 1989), it is necessary to interpret negative

transference and maladaptive defences and to clarify contradictory ego states early in

treatment. Clarifying misunderstanding of the therapists interpretation, usually evolved by

the patients projections, can help the patient to replace primitive defences by the higher-level

defences in order to strengthen their ego and diminish distortions in interpersonal

relationships. Masterson sees transference as the reflection of the patients primary

relationships (Waldinger & Gunderson, 1989, p. 14). After the acting out is controlled, the

therapists helps patient to differentiate between the current reality of therapy and transference

distortions based on real pas experiences by using interpretations. Adler (1979, in Waldinger

& Gunderson, 1989) argues that patients longing for a perfect caregiver is the thing that

holds borderline patient in therapy and that early interpretation would only disrupt the

relationship with the therapist and the patients motivation for treatment.

Transference based psychoanalytic therapies suggest facilitation of reactivating split-off

internalized object relations and idealized natures that are then observed and interpreted in

transference. The patient is instructed to carry out free associations, while the therapists

focuses on observing activation of regressive, split-off relations in the transference,

identyfing them and interpreting them. These interpretations are based on the assumption that

each split off object relation is a part of dyadic unit of self-representation, object-

representation and a dominant affect linking them. Activation of these dyadic relationships

forms the patients perception of the therapist, who might be perceived as object-

representation in one point, while the patient identifies with primitive self-object or vice versa

in another point of therapy session. The final goal of the therapy is to associate positive and

negative transferences, integrate mutually split off idealized and persecutory segments with

the corresponding resolution of identity diffusion (Williams, 2011).


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Borderline personality disorder across cultures

Mental disorders express themselves with different symptoms in each culture. Some

disorders are seen only in specific social settings. Personality disorders are particularly

socially sensitive because they refer to behaviours and feelings that are learned in certain

culture setting.

Moriya et al. (1993) conducted a clinical study of the borderline personality disorder in

Asia involving 85 female outpatients from Japan, 32 of them diagnosed with borderline

personality disorder. The results showed that there is a psychopathological entity equivalentto borderline personality disorder from USA in Asia, or at least in Japan. Japanese patients

scored approximately the same on anger and self-mutilating behaviour as American patients.

They scored less on substance abuse and drug induced psychotic experiences than

Americans. Japanese borderline patients showed tendency toward stormy or masochistic

relationships, and that few of them were independent (Moriya et al., 1993). Moriya argues

that it is due to the fact that most of the patients in Japan live with their parents and continue

to have such relationships with them, while American patients of that age live away from

their parents.

Bateman (1989) conducted a preliminary study of the borderline patients in Britain in

order to determine whether British patients fit into American diagnosis criteria presented in

DSM classifications. The results of the study showed that patients diagnosed with American

criteria have particular symptom profile which is not classified easily in any specific

diagnostic category used in Britain (Bateman, 1989).

When conducting cross-cultural studies on psychopathological disorders, it is always a

question whether diagnostic criteria suits the characteristics of the culture involved and their

terms of normality and sanity. Instruments used in the research represent another threat to

validity of the results of the study and their implications.


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Conclusion

Borderline personality disorder concept still needs to be investigated in order to providecomplete image of this disorder, the criteria for diagnosing it and differentiate it from other

psychological disorders in childhood. Demographic factors such as gender and age should be

further explored in context of borderline personality disorders in order to determine its

prevalence and critical age for developing the disorder.

Many factors influence developing personality disorders, among which are genes and

biological vulnerability, childhood trauma or disturbed psychological development, parental

figures and social factors including persons environment and cultural influences. All these

factors must be taken into account when discussing borderline personality. If genetic

material, diathesis and biological vulnerability cannot be changed, childs development,

family relationships and environment are the factors that could be influenced on by each

individual and the whole society in order to create a healthy context for growing up and

achieving personal well-being.

Social support system has to be provided for individuals suffering from this disorder andtheir environment in order to be able to handle the distress and behavioural changes the

patient experiences. Information about the borderline personality disorder need to be

available, so that individuals experiencing emotional disturbances could identify the nature of

their disturbances and seek appropriate help. Parents need to be educated in area of child

psychological functioning in order to prevent or recognize symptoms of any kind of

disturbances and start with treatment on time.

Psychotherapy for patients with personality disorders still represents a challenge.

Identifying the best approach for each individual and developing a trusting relationship is

difficult, especially if it is a patient with borderline personality disorder. Trust issues,

idealization and deep disappointments, mood changes and behavioural inconsistency can

pose great obstacle for progress in therapy. The therapist has to be cautious in approaching

them and uncovering the potential trauma they experienced so they do not disrupt patients

involvement in therapeutic process.


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And finally, cultural context of the borderline personality disorder needs to be studied in

different cultures, in order to establish the impact of culture on development of personality

disorders. There are few studies comparing borderline symptoms and phenomenology in

Eastern and Western societies. Common diagnosis criteria and instruments need to be

established, so the findings regarding etiological, phenomenological and treatment issues

could be applied in different societies.


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