Psychodynamic approaches to Borderline Personality Disorder

Psychodynamic approaches to Borderline Personality Disorder (BPD) are particularly relevant to understanding the aetiology, treatment, and even prevention of BPD. Psychodynamic approaches contribute an understanding of the core deficits surrounding identity, object relations (self and other relationships), and emotion dysregulation in terms of personality organisation, motivational processes (e.g., attachment needs), affects, conflict, and defences. Psychodynamic approaches complement non-psychodynamic approaches to BPD. There are two major psychodynamic approaches to treating BPD: Transference-Focused Psychotherapy and Mentalisation-based Treatments. Both have demonstrated clinical utility and share common features with respect to the development of selfand other-reflection. Both the conceptualisation and classification of personality disorders have received longstanding criticism for various reasons, including comorbidity and poor reliability of assessment. Nevertheless, the view that personality (however conceptualised) can be disordered is generally accepted, and psychodynamic approaches have a long history of contributing to both our description and understanding of 'character pathology'. Furthermore, psychodynamic accounts are particularly well-suited to understanding and guiding the treatment of personality disorders. 7 Borderline Personality Disorder8 DSM-IV provided for up to 256 different ways of diagnosing Borderline Personality Disorder (BPD) (American Psychiatric Association [APA], 2000; see Schmeck, SchlüterMüller, Foelsch, & Doering, 2013). While this heterogeneity suggests that no one-size-fits-all account will be sufficient (Clarkin et al., 2007), there are nevertheless core features of BPD found across both DSM-IV and DSM-5 that strongly implicate a psychodynamic approach to both understanding and treatment. These features include frantic efforts to avoid real or imagined abandonment, and unstable and conflicted interpersonal relationships characterised by alternating between extremes of idealisation and devaluation ('splitting'), identity disturbances (unstable self-image), impulsivity, affective instability (including intense anxiety and anger), and other dissociative phenomena such as depersonalisation (APA, 2013). The term 'borderline' first emerged in the psychoanalytic writings of Adolph Stern (1938) where it described individuals on the borderline of neurosis and psychosis. Borderline individuals generally retain both intact reality testing and (albeit neurotic) functioning which, nevertheless, breaks down under severe stress (see Bradley and Westen, 2005 for a historical review of BPD). One of the first clear references to BPD as a personality disorder is from Kernberg (1967) who restricted the use of 'borderline' to 'borderline personality organisation'. This personality organisation entailed a "pathological ego structure" rather than "a transitory state fluctuating between neurosis and psychosis" (pp. 641–642). Pathology entails ego-deficits (including failures to synthesise various object-relations) as well as specific defensive manoeuvres such as 'splitting' (idealisation and devaluation). While borderline personality organisation is a broader concept than BPD, in several