I Hate You--Don't Leave Me - Jerold J. Kreisman [102]
In the late 1920s and early 1930s, the followers of the British psychoanalyst Melanie Klein investigated the cases of many patients who seemed just beyond the reach of psychoanalysis. The Kleinians focused on psychological dynamics as opposed to biological-constitutional factors.
The term borderline was first coined by Adolph Stern in 1938 to describe a group of patients who did not seem to fit into the primary diagnostic classifications of “neuroses” and “psychoses.”2 These individuals were obviously more ill than neurotic patients—in fact, “too ill for classical psychoanalysis”—yet they did not, like psychotic patients, continually misinterpret the real world. Though, like neurotics, they displayed a wide range of anxiety symptoms, neurotic patients usually had a more solid, consistent sense of identity and used more mature coping mechanisms.
Throughout the 1940s and 1950s, other psychoanalysts began to recognize a population of patients who did not fit existing pathological descriptions. Some patients appeared to be neurotic or mildly symptomatic, but when they engaged in traditional psychotherapy, especially psychoanalysis, they “unraveled.” Similarly, hospitalization would also exacerbate symptoms and increase the patient’s infantile behavior and dependency on the therapist and hospital.
Other patients would appear to be severely psychotic, often diagnosed schizophrenic, only to make a sudden and unexpected recovery within a very short time. (Such dramatic improvement is inconsistent with the usual course of schizophrenia.) Still other patients exhibited symptoms suggestive of depression, but their radical swings in mood did not fit the usual profile of depressive disorders.
Psychological testing also confirmed the presence of a new, unique classification. Certain patients performed normally on structured psychological tests (such as IQ tests), but on unstructured, projective tests requiring narrative personalized responses (such as the Rorschach inkblot test), their responses were much more akin to those of psychotic patients, who displayed thinking and fantasizing on a more regressed, more childlike level.
During this postwar period, psychoanalysts fastened onto different aspects of the syndrome, seeking to develop a succinct delineation. In many ways the situation was like the old tale of the blind men who stood around an elephant and touched its various anatomical parts, trying to identify them. Each man described a different animal, of course, depending on which part he touched. Similarly, researchers were able to touch and identify different aspects of the borderline syndrome but could not quite see the whole organism. Many researchers (Zilboorg, Hoch and Polatin, Bychowski, and others)3,4,5 and DSM-II (1968)6 rallied around the schizophrenia-like aspects of the disorder, using such terms as “ambulatory schizophrenia,” “pre-schizophrenia,” “pseudoneurotic schizophrenia,” and “latent schizophrenia” to describe the illness. Others concentrated on these patients’ lack of a consistent, core sense of identity. In 1942, Helene Deutsch described a group of patients who overcame an intrinsic sense of emptiness by a chameleon-like altering of their internal and external emotional experiences to fit the people and situations they were involved with at the moment. She termed this tendency of adopting the qualities of others as a means of gaining or retaining their love the “as-if personality.”7
In 1953, Robert Knight revitalized the term borderline in his consideration of “borderline states.”8 He recognized that, even though certain patients presented markedly different symptoms and were categorized with different diagnoses, they were expressing a common pathology.
After Knight’s work was published, the term borderline became more popular, and the possibility of using Stern’s general borderline concept as a diagnosis