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2017 | OriginalPaper | Hoofdstuk

7. Visies op het borderlineconcept: verleden, heden en toekomst

Identiteitsdiffusie of complex geheel?

Auteurs : Dr. Jurrijn Koelen, Prof. dr. Patrick Luyten, Mevrouw prof. dr. Liesbeth Eurelings-Bontekoe

Gepubliceerd in: Handboek persoonlijkheidspathologie

Uitgeverij: Bohn Stafleu van Loghum

Samenvatting

In de geschiedenis zijn er talloze benaderingen met betrekking tot het ontstaan en de aard van borderlinepathologie ontwikkeld, waarbij de stoornis als subcategorie van de neurose, of als subcategorie van de psychose, of als zelfstandige entiteit werd benaderd. Wij menen dat (minimaal) acht benaderingen van of visies op het borderlineconcept kunnen worden onderscheiden. De visies worden in dit hoofdstuk verder toegelicht en beschreven; daarbij worden alle visies zoveel mogelijk vanuit hedendaags perspectief benaderd. Vele verschillende benaderingen verwijzen onzes inziens namelijk naar hetzelfde kernconcept, en wel een verstoorde affect- en stressregulatie. Ten slotte wordt ingehaakt op diagnostiek en indicatiestelling voor behandeling.

vorige hoofdstuk Categoriale classificatie, epidemiologie en comorbiditeit

volgende hoofdstuk Persoonlijkheidsstoornissen in DSM-5

Tegenwoordig worden de termen 'anaclitisch' en 'introjectief' veelal aangeduid met resp. 'relatiegerichtheid' (relatedness) en 'zelfdefiniëring' (self-definition) (Luyten en Blatt, 2016).

Het zal duidelijk zijn dat dit voor schizoïde en schizotypische borderlinepatiënten (Stone 1983) niet of nauwelijks geldt. Patiënten met sterk schizoïde of schizotypische trekken kenmerken zich immers door sociale anhedonie, affectieve vervlakking, teruggetrokkenheid en een voorkeur voor solistische activiteiten.

Belangrijk is hier te vermelden dat we nu het bipolaire type II½ van Akiskal (2004) buiten beschouwing laten. Eveneens laten we nu subklinische vormen van affectieve stoornissen (Akiskal 1981) onbesproken, wat verhindert dat een mogelijk grotere verwantschap tussen affectieve stoornissen en borderlinestoornissen aan het licht kan komen.

Een term ontleend aan Kohut (1971). Interessant in dit verband is dat Drew Westen en collega’s (Golomb et al.,1994) in een exploratieve empirische studie hebben aangetoond dat moeders van borderlinepatiënten ertoe neigden hun kind op zeer egocentrische wijze te bejegenen.

De ideeën van Fonagy omtrent de moeite die borderlinepatiënten ermee hebben te komen tot een realistische, gedifferentieerde representatie van (significante) anderen, vooral in de context van hechtingsrelaties (mentalisatie), hebben geleid tot de ontwikkeling van een psychodynamische behandelvorm specifiek voor de behandeling van de borderlinepersoonlijkheidsstoornis, namelijk Mentalization.

Hyperreactiviteit van de amygdala is door Donegan et al. (2003) recent in verband gebracht met borderlinepathologie (zie ook Herpertz et al., 2001).

Zoals eerder vermeld is slechts in 33% van de gevallen het gedragspatroon op elfjarige leeftijd in overeenstemming met het temperament, zodat high-reactiveness en inhibition niet altijd hand in hand gaan. Interessant in dit verband is echter dat Pukrop (2002) vond dat patiënten met BPS hoger scoorden op inhibitedness (DAPP) dan zowel de normale populatie als patiënten met andere DSM-IV-persoonlijkheidsstoornissen, in combinatie met verhoogde scores op neuroticism (FFM) en emotional dysregulation (DAPP) (stressreactiviteit).

De term ‘allostatic overload’ is afgeleid van het woord ‘allostase’ (letterlijk: evenwicht door verandering), dat dient ter vervanging van het traditionele woord ‘homeostase’. Allostase drukt beter uit dat het gaat om dynamische adaptatie, dus om een relatieve homeostase bij voortdurend veranderende innerlijke en uiterlijke omstandigheden. Dit proces zorgt ervoor dat wij ons met onze belangrijkste innerlijke systemen voortdurend (tijdelijk) kunnen aanpassen aan nieuwe omstandigheden, waardoor wij veerkrachtig kunnen zijn.

Widiger en Samuel (2005) merken terecht op dat de term ‘co-occurrence’ hier de voorkeur verdient, omdat hiermee niet de indruk wordt gewekt dat we spreken over verschillende ziektebeelden. Mogelijk zijn de verschillende persoonlijkheidsstoornissen (in DSM-IV) uitdrukking van gemeenschappelijke etiologische factoren (multifinaliteit), zoals genetische (bijv. temperament), neurobiologische (verstoorde cognitief-affectieve regulatie ten gevolge van vroege ‘life stress’), ontwikkelings- of persoonlijkheidsfactoren (zie ook Jongedijk, 2001; Luyten en Vliegen 2005).

Volgens de APA 1994) dienen persoonlijkheidstrekken – om te kunnen spreken van een persoonlijkheidsstoornis – inflexibel en onaangepast te zijn, en bovendien te leiden tot significante ondermijning van het functioneren of tot subjectief leed.

Uit een studie van Pukrop (2002), waarin de borderlinepersoonlijkheidsstoornis werd beschreven met verscheidene dimensionale modellen, bleek inderdaad dat deze persoonlijkheidsstoornis samenhangt met verhoogde scores op Emotional dysregulation, meer dan andere persoonlijkheidsstoornissen.

Lenzenweger en collega’s (2004) vonden inderdaad dat borderlinepatiënten lager scoorden op Nonaffective Constraint dan een controlegroep.

Blatt en Levy (2003), bijvoorbeeld, koppelen duidelijk de karakterstijl los van de persoonlijkheidsorganisatie (complexiteit). Zo onderscheiden zij binnen het anaclitische en het introjectieve cluster verschillende niveaus van complexiteit. Ze maken daarbij gebruik van de hechtingstheorie.

Voorbeelden van positieve persoonlijkheidstrekken zijn: zorgzaam, consciëntieus, netjes en betrouwbaar. Voorbeelden van negatieve persoonlijkheidstrekken: lusteloos, afhankelijk, onhandig, onbeschaamd, lomp, hardvochtig (voor meer voorbeelden zie Stone, 1993a, 1994).

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Titel: Visies op het borderlineconcept: verleden, heden en toekomst
Auteurs: Dr. Jurrijn Koelen
Prof. dr. Patrick Luyten
Mevrouw prof. dr. Liesbeth Eurelings-Bontekoe
Uitgeverij: Bohn Stafleu van Loghum
Boek: Handboek persoonlijkheidspathologie
Print ISBN: 978-90-368-0930-6

Elektronisch ISBN: 978-90-368-0931-3

Copyright: 2017
DOI: https://doi.org/10.1007/978-90-368-0931-3_7

Bohn Stafleu van Loghum

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