On the border between the psychotic and neurotic;

a framework for working with borderline states

Dr Chris Newrith

Consultant Psychiatrist in Psychotherapy

“Few disorders in psychiatry would warrant an entire volume devoted to the emotional reactions they generate in the clinicians who treat them. Borderline personality disorder is unique in its capacity to stir up feelings that overwhelm treaters”

Gabbard and Wilkinson, 1994

Personality Disorders – Diagnostic Categories ICD 10 DSM V

Paranoid Paranoid

Schizoid Schizoid

x Schizotypal

Anankastic Obsessive-Comp.

Histrionic Histrionic

Dependent Dependent

Dissocial Antisocial

x Narcissistic

Personality Disorders – Diagnostic Categories (II)

ICD DSM

Anxious Avoidant

Emotionally Unstable Borderline

- Impulsive

- Borderline

• Note: Use of ‘Clusters’ in DSM - Clusters A, B and C

DSM - Clusters

• Cluster A – move away from social attachments • Paranoid pd

• Schizoid pd

• Schizotypal pd

• Cluster C – move towards others for support • Avoidant pd

• Dependent pd

• Obsessive Compulsive pd

• Passive Aggressive pd

DSM Clusters (II)

• Cluster B – Push others away, but to do this first have to draw others to towards them • Antisocial pd

• Borderline pd

• Histrionic pd

• Narcissistic pd

The phrase “borderline” starts appearing in the psychoanalytic literature in the 1950s and 1960 – it describes a style of functioning where primitive internal processes, such as projective identification, splitting etc have variable intensity and range from a psychotic pattern of presentation to the neurotic.

This eventually becomes known as Borderline Personality Organisation.

In DSM III, the term is used to describe a category, a population of patients – Borderline Personality Disorder. This may be unhelpfully restrictive.

A developmental model of personality disorder One conceptual approach is to view the disorder as a problem with developing emotional robustness.

With good enough emotional support and input humans naturally progress through childhood, and then adult becoming increasingly emotionally robust – e.g. starting school

Deprived of these environmental supports, an individual makes erratic progress and is nowhere near as emotionally robust and adaptable as others – even though they are physically and intellectually fully adult.

Frequently they learn to cope by adapting their environments.

Psychodynamic vs categorical

Psychotic Neurotic

Poor reality orientation Reality orientated

Use of primitive defences Neurotic/mature defences

Use of Projective Identification ++

Splitting

Projection

Three Broad Principles for the Management of Individuals with PD

1) Stabilize the External Environment

2) Alter the internal environment

3) Control Countertransference (the clinician’s emotional response to the patient)

Vaillant, 1992

1) Stabilise the external environment

People with BPD do not cope as well as others in unpredictable environments.

Having been denied the opportunity to develop robust emotional constitutions, they rely on the external world being robust i.e. predictable, known, supportive.

Under stress they attempt to modify the external world.

1) Stabilise the external environment - cont

Therefore:

Be as predictable as possible, minimise uncertainty

Say what you’re going to do, and honour that e.g. timings

Pay close attention to transitions – make them as predictable as possible

If there are difficulties try and explore what they are

2) Alter the internal environment

“The limbic system was neurobiologically designed to be comforted by friendly people and not by chemistry” (Vaillant, 1992)

The importance of listening, and showing that you are able to tolerate listening – “Negative Capability” (Keats)

Use psychotropic medication for symptom relief (have a clear and agreed plan for starting and stopping)

“…Negative capability, that is when a man is capable of being in uncertainties, Mysteries, doubt, without any irritable reaching after fact and reason”

Keats, private letter, 1817

Use of psychotropic medication (Crawford, 2018)

3) Controlling countertransference

Notion of primitive communication – making you feel/ experience rather than articulating Projective Identification recruits people in to roles. Self monitor – what’s your natural state with a patient, and what may be different about how you’re currently responding? Transference – it’s not personal – it’s about who you represent, not who you really are Have people you can voice your frustrations to (Winnicott – Hate in the countertransference) c.f. being a parent or teacher

3) Controlling countertransference - cont Access to supervision (or at least a second mind to provide perspective)

Balint Groups

Watch the “Battle Fatigue” effect – cumulative wear and tear

Warning signs will come out at home, not at work