I Hate You--Don't Leave Me - Jerold J. Kreisman [103]
Yet, even with all this extensive pioneering research, the diagnosis of borderline personality, among working clinicians, was still drenched in ambiguity. It was considered a “wastebasket diagnosis” by many, a place to “dump” those patients who were not well understood, who resisted therapy, or who simply did not get better; the situation remained that way well into the 1970s.
As borderline personality became more rigorously defined and distinguishable from other syndromes, attempts were made to change the ambiguous name. At one point, “unstable personality” was briefly considered during the development of DSM-III. However, borderline character pathology is relatively fixed and invariable (at least for a considerable period) despite its chaos—it is predictably stable in its instability. No other names have been prominently proposed as a replacement.
In the 1960s and 1970s, two major schools of thought evolved to delineate a consistent set of criteria for defining the borderline syndrome. Like some other disciplines in the natural and social sciences, psychiatry was split ideologically into two primary camps—one more concept oriented, the other more influenced by descriptive, observable behavior that could be more easily retested and studied under laboratory conditions.
The empirical school, led by John G. Gunderson of Harvard and favored by many researchers, developed a structured, more behavioral definition, one based on observable criteria and thus more accessible to research and study. This definition is the most widely accepted and in 1980 was adopted by DSM-III and perpetuated in DSM-IV (see chapter 2).
The other more concept-oriented school, led by Otto Kernberg of Cornell and favored by many psychoanalysts, proposes a more psychostructural approach that describes the syndrome based on intrapsychic functioning and defense mechanisms rather than overt behaviors.
Kernberg’s “Borderline Personality Organization” (BPO)
In 1967, Otto Kernberg introduced his concept of Borderline Personality Organization (BPO), a broader concept than the current DSM-IV’s Borderline Personality Disorder. Kernberg’s conceptualization places BPO midway between neurotic and psychotic personality organization.10,11 A patient with BPO, as defined by Kernberg, is less impaired than a psychotic, whose perceptions of reality are severely contorted, making normal functioning impossible. On the other hand, the borderline is more disabled than a person with neurotic personality organization, who experiences intolerable anxiety as a result of emotional conflicts. The neurotic’s perception of identity and system of defense mechanisms are usually more adaptive than those of the borderline.
BPO encompasses other Axis II, or characterological disorders, such as paranoid, schizoid, antisocial, histrionic, and narcissistic personality disorders. In addition, it includes obsessive-compulsive and chronic anxiety disorders, hypochondriasis, phobias, sexual perversions, and dissociative reactions (such as dissociative identity disorder—also known as multiple personality disorder). In Kernberg’s system, patients currently diagnosed with BPD would constitute only about 10 to 25 percent of patients classified BPO. A patient diagnosed with BPD is conceived as occupying a lower functioning, higher severity level within the overall BPO diagnosis.
Though Kernberg’s system was not officially adopted by the APA, his work has had (and continues to have) significant influence as a theoretical model for both clinicians and researchers. In general, Kernberg’s schema emphasizes the inferred internal