CHILDHOOD EXPERIENCES ASSOCIATED WITH THE DEVELOPMENT OF BORDERLINE PERSONALITY DISORDER

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Borderline personality disorder (BPD) is a common and severe psychiatric disorder. It affects approximately 2% of US adults33 and is associated with high levels of psychiatric care and high levels of other types of social service use.29, 33 The etiology of BPD has been a source of intense clinical interest for more than 25 years. The first attempt to explain the development of BPD came from the psychoanalytic community, and three major psychodynamic theories of the pathogenesis of the disorder have been proposed.

In the first of these theories, Kernberg16 suggests that excessive early aggression leads young children to split their positive and negative images of themselves and their mothers. This excess aggression may have been inborn or it may have been caused by frustration. In either case, preborderline children are unable to merge their positive and negative images and attendant affects to achieve a more realistic and ambivalent view of themselves and others.

In the second of these theories, Adler and Buie1 suggest that failures in early mothering lead to a failure to develop stable object constancy. Because preborderline children's mothering is inconsistent and often insensitive and nonempathic, these children fail to develop a consistent view of themselves or others that they can use in times of stress to comfort and sustain themselves.

In the third of these theories, Masterson21 suggests that fear of abandonment is the central factor in borderline psychopathology. He believes that mothers of future borderline patients interfered with their children's natural autonomous strivings by withdrawing emotionally when these children acted in an independent manner during the phase of development that Mahler20 has termed separation– individuation. Later experiences that require independent behavior lead to a recrudescence of the dysphoria and abandonment panic that patients with BPD felt as children when faced with seemingly insoluble dilemmas (i.e., they continue to behave dependently or lose needed emotional support).

Section snippets

FIRST-GENERATION STUDIES OF THE PATHOGENESIS OF BORDERLINE PERSONALITY DISORDER

Although these theories contain much clinical wisdom, it was difficult for many observers to believe that such a severe psychiatric disorder would typically be the result of such relatively subtle childhood difficulties. Nonetheless, the first generation of studies of the environmental factors that might be of etiologic significance for BPD focused on issues raised in these psychodynamic theories. Two topics studied with care were: (1) parental separation or loss and (2) disturbed parental

SECOND-GENERATION STUDIES OF THE PATHOGENESIS OF BORDERLINE PERSONALITY DISORDER

The second generation of studies of the environmental factors that may be pathogenic for BPD build on the methodologic limitations of the studies just reviewed. Most of the second-generation studies that are reviewed here (Table 1) have incorporated the following three methodologic advances: (1) diagnoses were determined using semistructured interviews, (2) childhood experiences were assessed using semistructured interviews, and (3) diagnostic and childhood information was obtained blind to

THIRD-GENERATION STUDIES OF THE PATHOGENESIS OF BORDERLINE PERSONALITY DISORDER

Third-generation studies are described in this section (Table 1). These studies share several conceptual and methodologic features. Most important among these features are a tendency to assess a range of pathologic childhood experiences rather than focusing solely on the prevalence of sexual abuse, a tendency to more explicitly explore the important parameters of sexual abuse, and a tendency to use mutivariate analyses in determining significant findings.

Paris et al25, 26 from McGill University

CLINICAL ASSOCIATIONS OF SECOND-GENERATION AND THIRD-GENERATION STUDIES

Despite the robustness of the findings concerning childhood experiences of sexual abuse and their resonance with clinical experience over time with a variety of patients with BPD, a relatively small group of clinicians refuse to believe most accounts of childhood sexual abuse, no matter how spontaneous, richly detailed, and affectively compelling the account. These clinicians often ask patients for corroborating evidence despite the difficulty of obtaining such evidence and despite the fact

TOWARD A MULTIFACTORIAL MODEL OF THE CAUSE OF BORDERLINE PERSONALITY DISORDER

Several authors have suggested that a multifactorial model of the etiology of BPD best captures the complexity of BPD psychopathology.23, 38 This model suggests that BPD symptomatology and its comorbid manifestations are the end product of a complex admixture of innate temperament, difficult childhood experiences, and relatively subtle forms of neurologic and biochemical dysfunction (which may be sequelae of these childhood experiences or innate vulnerabilities).

This model is consistent with

SUMMARY

In time, mental health professionals will understand the etiology of BPD more fully. Although enormous strides have been made in the past decade, research into the multifactorial basis of BPD is still in its infancy. In particular, studies of children at high risk for developing BPD are needed. For now, the author suggests that one can admire patients with BPD for the integrity with which they have dealt with their pain. After all, not many people remain so loyal to and so respectful of such

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    Address reprint requests to Mary C. Zanarini, EdD, McLean Hospital, 115 Mill Street, Belmont, MA 02478, e-mail: [email protected]

    This article is supported, in part, by NIMH grant MH–47588.

    *

    Laboratory for the Study of Adult Development, McLean Hospital, Belmont, Massachusetts; and the Department of Psychology, Harvard Medical School, Boston, Massachusetts

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