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The psychodynamics of borderline personality disorder: A view from developmental psychopathology

Published online by Cambridge University Press:  12 December 2005

REBEKAH BRADLEY  and
DREW WESTEN
REBEKAH BRADLEY
Affiliation:
Emory University
DREW WESTEN
Affiliation:
Emory University
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Abstract

This article provides a contemporary view of the psychodynamics of borderline personality disorder (BPD) from a developmental psychopathology perspective. We first briefly describe the evolution of the borderline construct in psychoanalysis and psychiatry. Then we provide clinically and empirically informed model of domains of personality function and dysfunction that provides a roadmap for thinking about personality pathology from a developmental psychopathology standpoint and examine the nature and phenomenology of BPD in terms of these domains of functioning. Next, we describe prominent dynamic theories of etiology of BPD and examine these in relation to the available research. Finally, we describe psychodynamic conceptions of treatment and the way BPD phenomena manifest in treatment, followed again by consideration of relevant research, particularly on transference–countertransference constellations empirically identified in the treatment of patients with BPD.Preparation of this article was supported in part by NIMH Grants R01-MH62377 and R01-MH62378.

Type
Research Article
Information
Development and Psychopathology , Volume 17 , Issue 4 , December 2005 , pp. 927 - 957
Copyright
© 2005 Cambridge University Press

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References

REFERENCES

Ackerman, S. J., Hilsenroth, M. J., Clemence, A. J., Weatherill, R., & Fowler, J. C. (2000). The effects of social cognition and object representation on psychotherapy continuation. Bulletin of the Menninger Clinic 64, 386–408.Google Scholar
Adler, G. (1981). The borderline-narcissistic personality disorder continuum. American Journal of Psychiatry 138, 46–50.Google Scholar
Adler, G. (1989). Uses and limitations of Kohut's self psychology in the treatment of borderline patients. Journal of the American Psychoanalytic Association 37, 761–785.Google Scholar
Adler, G., & Buie, D. (1979). Aloneness and borderline psychopathology: The possible relevance of child development issues. International Journal of PsychoAnalysis 60, 83–96.Google Scholar
Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons–Ruth, K. (2004). Attachment studies with borderline patients: A review. Harvard Review of Psychiatry 12, 94–104.Google Scholar
Akhtar, S. (1984). The syndrome of identity diffusion. American Journal of Psychiatry 141, 1381–1385.Google Scholar
Akhtar, S. (1992). Broken structures: Severe personality disorders and their treatment. Northvale, NJ: Jason Aronson, Inc.
Akiskal, H. S. (1996). The prevalent clinical spectrum of bipolar disorders: Beyond DSM-IV. Journal of Clinical Psychopharmacology 16, 4S–14S.Google Scholar
Akiskal, H. S. (2004). Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatrica Scandinavica 110, 401–407.Google Scholar
Akiskal, H. S., Chen, S. E., Davis, G. C., Parzantian, V. R., Kashgarian, M., & Bolinger, J. M. (1985). Borderline: An adjective in search of a noun. Journal of Clinical Psychiatry 46, 41–48.Google Scholar
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis (Vol. 4). New York: Analytic Press.
Baker, L., Silk, K. R., Westen, D., Nigg, J. T., & Lohr, N. E. (1992). Malevolence, splitting, and parental ratings by borderlines. The Journal of Nervous and Mental Disease 180, 258–264.Google Scholar
Bateman, A., & Fonagy, P. (1999). The effectiveness of partial hospitalisation in the treatment of borderline personality disorder—A randomised controlled trial. American Journal of Psychiatry 156, 1563–1569.Google Scholar
Bateman, A., & Fonagy, P. (2001). Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. American Journal of Psychiatry 158, 36–41.Google Scholar
Bateman, A. W., & Fonagy, P. (2003). The development of an attachment-based treatment program for borderline personality disorder. Bulletin of the Menninger Clinic 67, 187–211.Google Scholar
Bazanis, E., Rogers, R. D., Dowson, J. H., Taylor, P., Meux, C., Staley, C., et al. (2002). Neurocognitive deficits in decision-making and planning of patients with DSM-III-R borderline personality disorder. Psychological Medicine 32, 1395–1405.Google Scholar
Beck, J. C., & Van der Kolk, B. (1987). Reports of childhood incest and current behavior of chronically hospitalized psychotic women. American Journal of Psychiatry 144, 1474–1476.Google Scholar
Bell, M., Billington, R., Cicchetti, D., & Gibbons, J. (1988). Do object relations deficits distinguish BPD from other diagnostic groups? Journal of Clinical Psychology 44, 511–516.Google Scholar
Betan, E., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry 162, 890–898.Google Scholar
Betan, E., & Westen, D. (2005). Identity disturbance in adolescents with personality pathology. Unpublished manuscript, Emory University.
Blais, M. A., Hilsenroth, M. J., Fowler, J., & Conboy, C. A. (1999). A Rorschach exploration of the DSM-IV borderline personality disorder. Journal of Clinical Psychology 55, 563–572.Google Scholar
Blanck, G., & Blanck, R. (1974). Ego psychology: Theory and practice. Oxford: Columbia University Press.
Blanck, G., & Blanck, R. (1979). Ego psychology II: Theory and practice. New York: Columbia University Press.
Blatt, S. J., Brenneis, C., Schimek, J. G., & Glick, M. (1976). Normal development and psychopathological impairment of the concept of the object on the Rorschach. Journal of Abnormal Psychology 85, 364–373.Google Scholar
Bolton, S., & Gunderson, J. (1996). Distinguishing borderline personality disorder from bipolar disorder: Differential diagnosis and implications. American Journal of Psychiatry 153, 1202–1207.Google Scholar
Bowlby, J. (1969). Attachment (Vol. 1). New York: Basic Books.
Bowlby, J. (1973). Separation (Vol. 2). London: Hogarth Press.
Bowlby, J. (1980). Attachment and loss. New York: Basic Books.
Bradley, R., Heim, A., & Westen, D. (2005). Transference phenomena in the psychotherapy of personality disorders: An empirical investigation. British Journal of Psychiatry 186, 342–349.Google Scholar
Bradley, R., Jenei, J., & Westen, D. (2005). Etiology of borderline personality disorder: Disentangling the contributions of intercorrelated antecedents. Journal of Nervous and Mental Disease 193, 24–31.Google Scholar
Bradley, S. J. (1979). The relationship of early maternal separation to borderline personality in children and adolescents: A pilot study. American Journal of Psychiatry 136, 424–426.Google Scholar
Brenner, C. (1982). The mind in conflict. New York: International Universities Press.
Buie, D. H., & Adler, G. (1982). Definitive treatment of the borderline personality. International Journal of Psychoanalytic Psychotherapy 9, 51–87.Google Scholar
Butler, R. W., Mueser, K. T., Sprock, J., & Braff, D. L. (1996). Positive symptoms of psychosis in posttraumatic stress disorder. Biological Psychiatry 39, 839–844.Google Scholar
Cardasis, W., Hochman, J. A., & Silk, K. R. (1997). Transitional objects and borderline personality disorder. American Journal of Psychiatry 154, 250–255.Google Scholar
Caspi, A., McClay, J., Moffitt, T., Mill, J., Martin, J., Craig, I. W., et al. (2002). Role of genotype in the cycle of violence in maltreated children. Science 297, 851–854.Google Scholar
Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., et al. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science 301, 386–389.Google Scholar
Cassidy, J. (1988). Child–mother attachment and the self in six-year-olds. Child Development 59, 121–134.Google Scholar
Cicchetti, D., Ackerman, B. P., & Izard, C. E. (1995). Emotions and emotion regulation in developmental psychopathology. Development and Psychopathology 7, 1–10.Google Scholar
Cicchetti, D., & Toth, S. L. (2000). Developmental processes in maltreated children. Nebraska Symposium on Motivation 46, 85–160.Google Scholar
Clarkin, J. F., Foelsch, P. A., Levy, K. N., Hull, J. W., Delaney, J. C., & Kernberg, O. F. (2001). The development of a psychodynamic treatment for patients with borderline personality disorder: A preliminary study of behavioral change. Journal of Personality Disorders 15, 487–495.Google Scholar
Clarkin, J. F., Kernberg, O. F., & Somavia, J. (1998). Assessment of the patient with borderline personality disorder for psychodynamic treatment [References]. In J. W. Barron (Ed.), Making diagnosis meaningful: Enhancing evaluation and treatment of psychological disorders (pp. 299–318). Washington, DC: American Psychological Association.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2004). The Personality Disorders Institute/Borderline Personality Disorder Research Foundation Randomized Control Trial for Borderline Personality Disorder: Rationale, methods, and patient characteristics. Journal of Personality Disorders 18, 52–72.Google Scholar
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (1999). Psychotherapy for borderline personality. New York: Wiley.
Cleckley, H. (1941). The mask of sanity. St. Louis, MO: Mosby.
Coccaro, E. F., Siever, L. J., Klar, H. M., Maurer, G., Cochrane, K., Cooper, T. B., et al. (1989). Serotonergic studies in patients with affective and personality disorders: Correlates with suicidal and impulsive aggressive behavior. Archives of General Psychiatry 46, 587–599.Google Scholar
Critchfield, K. L., Levy, K. N., & Clarkin, J. F. (2004). The relationship between impulsivity, aggression, and impulsive–aggression in borderline personality disorder: An empirical analysis of self-report measures. Journal of Personality Disorders 18, 555–570.Google Scholar
Dahl, A. (1995). Borderline disorders—The validity of the diagnostic concept. Psychiatric Development 3, 109–152.Google Scholar
Damon, W., & Hart, D. (1988). Self-understanding in childhood and adolescence. New York: Cambridge University Press.
Depue, R. A., & Lenzenweger, M. F. (2001). A neurobehavioral dimensional model. In W. Livesley (Ed.), Handbook of personality disorders: Theory, research, and treatment (pp. 136–176). New York: Guilford Press.
Depue, R. A., & Lenzenweger, M. F. (2005). A neurobehavioral dimensional model of personality disturbance [References]. In M. F. Lenzenweger & J. F. Clarkin (Eds.), Major theories of personality disorder (2nd ed., pp. 391–453). New York: Guilford Press.
Diguer, L., Pelletier, S., Hebert, E., Descoteaux, J., Rousseau, J.-P., & Daoust, J.-P. (2004). Personality organizations, psychiatric severity, and self and object representations. Psychoanalytic Psychology 21, 259–275.Google Scholar
Donegan, N. H., Sanislow, C. A., Blumberg, H. P., Fulbright, R. K., Lacadie, C., Skudlarski, P., et al. (2003). Amygdala hyperreactivity in borderline personality disorder: Implications for emotional dysregulation. Biological Psychiatry 54, 1284–1293.Google Scholar
Dong, M., Anda, R. F., Felitti, V. J., Dube, S. R., Williamson, D. F., Thompson, T. J., et al. (2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse and Neglect 28, 771–784.Google Scholar
Downey, G., Freitas, A. L., Michaelis, B., & Khouri, H. (1998). The self-fulfilling prophecy in close relationships: Rejection sensitivity and rejection by romantic partners. Journal of Personality and Social Psychology 75, 545–560.Google Scholar
Driessen, M., Herrmann, J., Stahl, K., Zwaan, M., Meier, S., Hill, A., et al. (2000). Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Archives of General Psychiatry 57, 1115–1122.Google Scholar
Edwards, V. J., Holden, G. W., Anda, R. F., & Felitti, V. J. (2003). Experiencing multiple forms of childhood maltreatment and adult mental health: Results from the Adverse Childhood Experiences (ACE) Study. American Journal of Psychiatry 160, 1453–1460.Google Scholar
Erikson, E. (1986). Childhood and society. New York: W. W. Norton.
Erikson, E. H. (1962). Reality and actuality. Journal of the American Psychoanalytic Association 10, 451–474.Google Scholar
Fertuck, E. A., Lenzenweger, M., Clarkin, J. F., Hoermann, S. E., & Stanley, B. A. (in press). Executive neurocognition, memory systems, and borderline personality disorder. Clinical Psychology Review.
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York: Other Press.
Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant–mother attachment at one year of age. Child Development 62, 891–905.Google Scholar
Fonagy, P., & Target, M. (2000). The place of psychodynamic theory in developmental psychopathology. Development and Psychopathology 12, 407–425.Google Scholar
Fonagy, P., Target, M., & Gergely, G. (2000). Attachment and borderline personality disorder. Psychiatric Clinics of North America 23, 103–122.Google Scholar
Fonagy, P., Target, M., Gergely, G., Allen, J. G., & Bateman, A. (2003). The developmental roots of borderline personality disorder in early attachment relationships: A theory and some evidence. Psychoanalytic Inquiry 23, 412–459.Google Scholar
Fowler, J., Hilsenroth, M. J., & Nolan, E. (2000). Exploring the inner world of self-mutilating borderline patients: A Rorschach investigation. Bulletin of the Menninger Clinic 64, 365–385.Google Scholar
Frank, H., & Hoffman, N. (1986). Borderline empathy: An empirical investigation. Comprehensive Psychiatry 27, 387–395.Google Scholar
Frank, H., & Paris, J. (1981). Recollections of family experience in borderline patients. Archives of General Psychiatry 38, 1031–1034.Google Scholar
Freud, A., & Burlingham, D. T. (1944). Infants without families: The case for and against residential nurseries. Oxford: International University Press.
Freud, S. (1933). New introductory lectures on psycho-analysis. New York: W.W. Norton.
Frosch, J. (1970). Psychoanalytic considerations of the psychotic character. Journal of the American Psychoanalytic Association 18, 24–50.Google Scholar
Gabbard, G. (1989). On “doing nothing” in analytic treatment refractory borderline. Unpublished manuscript.
Gabbard, G. O. (2005). Psychodynamic psychiatry in clinical practice (4th ed.). Washington, DC: American Psychiatric Association.
Gabbard, G. O., & Wilkinson, S. M. (1994). Management of countertransference with borderline patients. Washington, DC: American Psychiatric Association.
Gartner, J., Hurt, S. W., & Gartner, A. (1989). Psychological test signs of borderline personality disorder: A review of the empirical literature. Journal of Personality Assessment 53, 423–441.Google Scholar
Gershuny, B. S., & Thayer, J. F. (1999). Relations among psychological trauma, dissociative phenomena, and trauma-related distress: A review and integration. Clinical Psychology Review 19, 631–657.Google Scholar
Goldberg, R. L., Mann, L. S., Wise, T. N., & Segall, E. A. (1985). Parental qualities as perceived by borderline personality disorders. Hillside Journal of Clinical Psychiatry 7, 134–140.Google Scholar
Greene, L. R. (1996). Primitive defenses, object relations, and symptom clusters in borderline psychopathology. Journal of Personality Assessment 67, 294–304.Google Scholar
Grinker, R. R., Werble, B., & Drye, R. (1968). The borderline syndrome: A behavioral study of ego functions. New York: Basic Books.
Gunderson, J. G. (2001). Borderline personality disorder: A clinical guide. Washington, DC: American Psychiatric Association.
Gunderson, J. G., Kerr, J., & Englund, D. W. (1980). The families of borderlines: A comparative study. Archives of General Psychiatry 37, 27–33.Google Scholar
Gunderson, J. G., & Kolb, J. E. (1978). Discriminating features of borderline patients. American Journal of Psychiatry 135, 792–796.Google Scholar
Gunderson, J. G., Kolb, J. E., & Austin, V. (1981). The diagnostic interview for borderline patients. American Journal of Psychiatry 138, 896–903.Google Scholar
Gunderson, J. G., & Phillips, K. A. (1991). A current view of the interface between borderline personality disorder and depression. American Journal of Psychiatry 148, 967–975.Google Scholar
Gunderson, J. G., & Sabo, A. N. (1993). “Borderline personality disorder and PTSD”: Reply. American Journal of Psychiatry 150, 1906–1907.Google Scholar
Gunderson, J. G., & Singer, M. T. (1975). Defining borderline patients: An overview. American Journal of Psychiatry 132, 1–10.Google Scholar
Gunderson, J. G., Zanarini, M. C., & Kisiel, C. (1995). Borderline personality disorder. In W. J. Livesley (Ed.), The DSM-IV personality disorders. New York: Guilford Press.
Harris, T., Brown, G. W., & Bifulco, A. (1986). Loss of parent in childhood and adult psychiatric disorder: The role of parental care. Psychological Medicine 16, 641–659.Google Scholar
Harter, S. (1999). The construction of the self: A developmental perspective. New York: Guilford Press.
Hartmann, H. (1939/1958). Ego psychology and the problem of adaptation. Oxford: International Universities Press.
Heaton, R. K. (1981). A manual for the Wisconsin Card Sorting Test. Odessa, FL: Psychological Assessment Resources.
Heim, A., & Westen, D. (in press). Theories of personality and personality disorders. In J. Oldham, A. Skodol, & D. Bender (Eds.), Textbook of personality disorders. Washington, DC: American Psychiatric Press.
Heim, C., Meinlschmidt, G., & Nemeroff, C. B. (2003). Neurobiology of early-life stress. Psychiatric Annals 33, 18–26.Google Scholar
Herman, J. L., Perry, J., & Van der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry 146, 490–495.Google Scholar
Herpertz, S. C., Dietrich, T. M., Wenning, B., Krings, T., Erberich, S. G., Willmes, K., et al. (2001). Evidence of abnormal amygdala functioning in borderline personality disorder: A functional MRI study. Biological Psychiatry 50, 292–298.Google Scholar
Higgins, E. T. (1990). Personality, social psychology, and person–situation relations: Standards and knowledge activation as a common language. In L. Pervin (Ed.), Handbook of personality: Theory and research (pp. 301–338). New York: Guilford Press.
Hoermann, S. E., Clarkin, J. F., Levy, K. N., & Hull, J. W. (2005). The construct of effortful control: An approach to BPD heterogeneity. Psychopathology 38, 82–86.Google Scholar
Hoffman, P. J., & McGlashan, T. (2003). A developmental model of borderline personality disorder: Understanding variations in course and outcome. Arlington, VA: American Psychiatric Association.
Johnson, J. G., Cohen, P., Smailes, E., Skodol, A., Brown, J., & Oldham, J. (2001). Childhood verbal abuse and risk for personality disorders during adolescence and early adulthood. Comprehensive Psychiatry 42, 16–23.Google Scholar
Judd, P. H., & McGlashan, T. (2003). A Developmental model of borderline personality disorder: Understanding variations in course and outcome. Washington, DC: American Psychiatric Association.
Judd, P. H., & Ruff, R. M. (1993). Neuropsychological dysfunction in borderline personality disorder. Journal of Personality Disorders 7, 275–284.Google Scholar
Kaplan, C. J. (1987). Children's responses to the loss of a parent: The interaction between the family and the intrapsychic mourning process. Unpublished manuscript, University of Massachusetts.
Kernberg, O. (1975). Borderline conditions and pathological narcissism. Northvale, NJ: Jason Aronson.
Kernberg, O. (1976). Technical considerations in the treatment of borderline personality organization. Journal of the American Psychoanalytic Association 24, 795–829.Google Scholar
Kernberg, O. (1983). Object relations theory and character analysis. Journal of the American Psychoanalytic Association 31, 247–272.Google Scholar
Kernberg, O. (1989). Severe personality disorders. New Haven, CT: Yale University Press.
Kim–Cohen, J., Caspi, A., Rutter, M., Thomas, M. P., & Moffitt, T. (2005). The caregiving environments provided to children by depressed mothers with or without an antisocial history. Unpublished manuscript, King's College, London.
Klaczynski, P., & Narasimham, G. (1998). Development of scientific reasoning biases: Cognitive versus ego-protective explanations. Developmental Psychology 34, 175–187.Google Scholar
Klein, R. (1989). Introduction to the disorders of the self. In J. F. Masterson & R. Klein (Eds.), Psychotherapy of the disorders of the self. New York: Brunner/Mazel.
Knight, R. P. (1953). Borderline states. Bulletin of the Menninger Clinic 17, 1–12.Google Scholar
Kohut, H. (1977). The restoration of the self. Madison, WI: International Universities Press, Inc.
Korfine, L., & Hooley, J. M. (2000). Directed forgetting of emotional stimuli in borderline personality disorder. Journal of Abnormal Psychology 109, 214–221.Google Scholar
Krystal, H. (1974). The genetic development of affects and affect regression. Annual of Psychoanalysis 2, 98–126.Google Scholar
Kullgren, G. (1988). Factors associated with completed suicide in borderline personality disorder. Journal of Nervous and Mental Disease 176, 40–44.Google Scholar
Kunert, H. J., Druecke, H. W., Sass, H., & Herpertz, S. C. (2003). Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings. Journal of Personality Disorders 17, 497–509.Google Scholar
Kurtz, J. E., & Morey, L. C. (1998). Negativism in evaluative judgments of words among depressed outpatients with borderline personality disorder. Journal of Personality Disorders 12, 351–361.Google Scholar
Leichsenring, F. (2004). Quality of depressive experiences in borderline personality disorders: Differences between patients with borderline personality disorder and patients with higher levels of personality organization. Bulletin of the Menninger Clinic 68, 9–22.Google Scholar
Lenzenweger, M. F., Clarkin, J. F., Fertuck, E. A., & Kernberg, O. F. (2004). Executive neurocognitive functioning and neurobehavioral systems indicators in borderline personality disorder: A preliminary study. Journal of Personality Disorders 18, 421–438.Google Scholar
Lenzenweger, M. F., Clarkin, J. F., Kernberg, O. F., & Foelsch, P. A. (2001). The Inventory of Personality Organization: Psychometric properties, factorial composition, and criterion relations with affect, aggressive dyscontrol, psychosis proneness, and self-domains in a nonclinical sample. Psychological Assessment 13, 577–591.Google Scholar
Linehan, M. (1993a). Skills-training manual for treatment of borderline personality disorder. New York: Guilford Press.
Linehan, M. M. (1993b). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry 48, 1060–1064.Google Scholar
Linehan, M. M., & Heard, H. L. (1992). Dialectical behavior therapy for borderline personality disorder. In J. F. Clarkin, E. Marziali, & H. Munroe–Blum (Eds.), Borderline personality disorder: Clinical and empirical perspectives (pp. 248–267). New York: Guilford Press.
Links, P. S., Heslegrave, R., & van Reekum, R. (1999). Impulsivity: Core aspect of borderline personality disorder. Journal of Personality Disorders 13, 1–9.Google Scholar
Links, P. S., Steiner, M., Offord, D. R., & Eppel, A. B. (1988). Characteristics of borderline personality disorder: A Canadian study. Canadian Journal of Psychiatry 33, 336–340.Google Scholar
Livesley, W. J., & Bromley, D. B. (1973). Person perception in childhood and adolescence. London: Wiley.
Ludolph, P., Westen, D., Misle, B., Jackson, A., Wixom, J., & Weiss, F. C. (1990). The borderline diagnosis in adolescents: Symptoms and developmental history. American Journal of Psychiatry 147, 470–476.Google Scholar
Lyons–Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganized early attachment patterns. Journal of Consulting and Clinical Psychology 64, 64–73.Google Scholar
Lyons–Ruth, K., Easterbrooks, M., & Cibelli, C. D. (1997). Infant attachment strategies, infant mental lag, and maternal depressive symptoms: Predictors of internalizing and externalizing problems at age 7. Developmental Psychology 33, 681–692.Google Scholar
Lyons–Ruth, K., & Jacobvitz, D. (1999). Attachment disorganization: Unresolved loss, relational violence, and lapses in behavioral and attentional strategies. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (pp. 550–554). New York: Guilford Press.
Lyons–Ruth, K., Yellin, C., Melnick, S., & Atwood, G. (2005). Expanding the concept of unresolved mental states: Hostile/helpless states of mind on the Adult Attachment Interview are associated with disrupted mother–infant communication and infant disorganization. Development and Psychopathology 17, 1–23.Google Scholar
Macfie, J., Houts, R. M., McElwain, N. L., & Cox, M. J. (2005). The effect of father–toddler and mother–toddler role reversal on the development of behavior problems in kindergarten. Social Development 14, 514–531.Google Scholar
Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. New York: Basic Books.
Main, M. (1995). Recent studies in attachment: Overview, with selected implications for clinical work. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment theory: Social, developmental, and clinical perspectives (pp. 407–474). Hillsdale, NJ: Analytic Press.
Main, M., & Goldwyn, R. (1985). Adult Attachment Classification System. Unpublished manuscript, University of California, Berkeley.
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development 50(1–2), 66–104.Google Scholar
Main, T. F. (1957). The ailment. British Journal of Medical Psychology 30, 129–145.Google Scholar
Mann, J. (1998). The role of in vivo neurotransmitter system imaging studies in understanding major depression. Biological Psychiatry 44, 1077–1078.Google Scholar
Masterson, J. (1972). Treatment of the borderline adolescent: A developmental approach. New York: Wiley.
Masterson, J. (1976). Psychotherapy of the borderline adult: A developmental approach. New York: Brunner/Mazel.
Masterson, J. F. (1978). The borderline adult: Therapeutic alliance and transference. American Journal of Psychiatry 135, 437–441.Google Scholar
Masterson, J. F., & Rinsley, D. B. (1975). The borderline syndrome: The role of the mother in the genesis and psychic structure of the borderline personality. International Journal of Psycho-Analysis 56, 163–177.Google Scholar
McLean, L. M., & Gallop, R. (2003). Implications of childhood sexual abuse for adult borderline personality disorder and complex posttraumatic stress disorder. American Journal of Psychiatry 160, 369–371.Google Scholar
McWilliams, N. (1999). Psychoanalytic case formulation. New York: Guilford Press.
Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Cambridge, MA: Harvard University Press.
Montgomery, S. A., Montgomery, D., Baldwin, D., & Green, M. (1989). Intermittent 3-day depressions and suicidal behaviour. Neuropsychobiology 145, 573–577.Google Scholar
Morrison, A. P., Frame, L., & Larkin, W. (2003). Relationships between trauma and psychosis: A review and integration. British Journal of Clinical Psychology 42, 331–353.Google Scholar
Nakash–Eisikovits, O., Dutra, L., & Westen, D. (2002). Relationship between attachment patterns and personality pathology in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 41, 1111–1123.Google Scholar
Nigg, J. T., & Goldsmith, H. (1994). Genetics of personality disorders: Perspectives from personality and psychopathology research. Psychological Bulletin 115, 346–380.Google Scholar
Nigg, J. T., Lohr, N. E., Westen, D., Gold, L. J., & Silk, K. R. (1992). Malevolent object representations in borderline personality disorder and major depression. Journal of Abnormal Psychology 101, 61–67.Google Scholar
Nigg, J. T., Silk, K. R., Westen, D., Lohr, N. E., Gold, L. J., Goodrich, S., et al. (1991). Object representations in the early memories of sexually abused borderline patients. American Journal of Psychiatry 148, 864–869.Google Scholar
Ogata, S. N., Silk, K. R., Goodrich, S., Lohr, N. E., Westen, D., & Hill, E. M. (1990). Childhood sexual and physical abuse in adult patients with borderline personality disorder. American Journal of Psychiatry 147, 1008–1013.Google Scholar
O'Leary, K. M. (2000). Neuropsychological testing results. Psychiatric Clinics of North America 23, 41–60.Google Scholar
Paris, J. (2003). Personality disorders over time: Precursors, course, and outcome. Washington, DC: American Psychiatric Association.
Paris, J., & Frank, H. (1989). Perceptions of parental bonding in borderline patients. American Journal of Psychiatry 146, 1498–1499.Google Scholar
Paris, J., Nowlis, D., & Brown, R. (1988). Developmental factors in the outcome of borderline personality disorder. Comprehensive Psychiatry 29, 147–150.Google Scholar
Perry, J. C., & Cooper, S. H. (1987). Empirical studies of psychological defense mechanisms. In R. Michels & J. O. J. Caenar (Eds.), Psychiatry. Philadelphia, PA: J.B. Lippincott.
Posner, M. I., Rothbart, M. K., Vizueta, N., Levy, K., Evans, D. E., & Thomas, K. M. (2002). Mechanisms of borderline personality disorder. Proceedings of the National Academy of Sciences of the United States of America 99, 16366–16370.Google Scholar
Read, J., & Argyle, N. (1999). Hallucinations, delusions, and thought disorder among adult psychiatric inpatients with a history of child abuse. Psychiatric Services 50, 1467–1472.Google Scholar
Redl, F., & Wineman, D. (1951). Children who hate: The disorganization and breakdown of behavior controls. Glencoe, IL: Free Press.
Rogers, J. H., Widiger, T. A., & Krupp, A. (1995). Aspects of depression associated with borderline personality disorder. American Journal of Psychiatry 152, 268–270.Google Scholar
Russ, E., Heim, A., & Westen, D. (2003). Parental bonding and personality pathology assessed by clinician report. Journal of Personality Disorders 17, 522–536.Google Scholar
Salzman, J. P., Salzman, C., & Wolfson, A. N. (1997). Relationship of childhood abuse and maternal attachment to the development of borderline personality disorder. In M. C. Zanarini (Ed.), Role of sexual abuse in the etiology of borderline personality disorder. Progress in psychiatry (Vol. 49, pp. 71–91). Washington, DC: American Psychiatric Association.
Schmahl, C. G., Elzinga, B. M., Ebner, U. W., Simms, T., Sanislow, C., Vermetten, E., et al. (2004). Psychophysiological reactivity to traumatic and abandonment scripts in borderline personality and posttraumatic stress disorders: A preliminary report. Psychiatry Research 126, 33–42.Google Scholar
Schmahl, C. G., Elzinga, B. M., Vermetten, E., Sanislow, C., McGlashan, T. H., & Bremner, J. (2003). Neural correlates of memories of abandonment in women with and without borderline personality disorder. Biological Psychiatry 54, 142–151.Google Scholar
Searles, H. (1979). The Countertransference with the borderline patient. In J. Leboit & A. Capponi (Eds.), Advances in psychotherapy with the borderline patient. New York: Aronson.
Segal, H. G., Westen, D., Lohr, N. E., & Silk, K. R. (1993). Clinical assessment of object relations and social cognition using stories told to the picture arrangement subtest of WAIS-R. Journal of Personality Assessment 61, 58–80.Google Scholar
Seroczynski, A. D., Bergeman, C. S., & Coccaro, E. F. (1999). Etiology of the impulsivity/aggression relationship: Genes or environment? Psychiatry Research 86, 41–57.Google Scholar
Shapiro, E. R. (1978). Research on family dynamics: clinical implications for the family of the borderline adolescent. Adolescent Psychiatry 6, 360–376.Google Scholar
Shapiro, E. R. (1982). The holding environment and family therapy with acting out adolescents. International Journal of Psychoanalysis 9, 209–226.Google Scholar
Shedler, J., & Westen, D. (2004). Refining personality disorder diagnoses: Integrating science and practice. American Journal of Psychiatry 161, 1350–1365.Google Scholar
Silk, K. R., Lee, S., Hill, E. M., & Lohr, N. E. (1995). Borderline personality disorder symptoms and severity of sexual abuse. American Journal of Psychiatry 152, 1059–1064.Google Scholar
Silk, K. R., Lohr, N. E., Ogata, S. N., & Westen, D. (1990). Borderline inpatients with affective disorder: Preliminary follow-up data. Journal of Personality Disorders 4, 213–224.Google Scholar
Skodol, A., Siever, L., Livesley, W., Gunderson, J., Pfohl, B., & Widiger, T. (2002). The borderline diagnosis II: Biology, genetics, and clinical course. Biological Psychiatry 51, 951–963.Google Scholar
Skodol, A. E., Gunderson, J., Pfohl, B., Widiger, T. A., Livesley, W. J., & Siever, L. (2002). The borderline diagnosis I: Psychopathology, comorbidity, and personality structures. Biological Psychiatry 51, 936–950.Google Scholar
Skodol, A. E., Gunderson, J. G., McGlashan, T. H., Dyck, I. R., Stout, R. L., Bender, D. S., et al. (2002). Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive–compulsive personality disorder. American Journal of Psychiatry 159, 276–283.Google Scholar
Soloff, P. H., Lis, J. A., Kelly, T., Cornelius, J. R., & Ulrich, R. (1994). Risk factors for suicidal behavior in borderline personality disorder. American Journal of Psychiatry 151, 1316–1323.Google Scholar
Soloff, P. H., Lynch, K. G., Kelly, T. M., Malone, K. M., & Mann, J. (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: A comparative study. American Journal of Psychiatry 157, 601–608.Google Scholar
Soloff, P. H., & Millward, J. W. (1983). Developmental histories of borderline patients. Comprehensive Psychiatry 24, 574–588.Google Scholar
Solomon, J., George, C., & De Jong, A. (1995). Children classified as controlling at age six: Evidence of disorganized representational strategies and aggression at home and at school. Development and Psychopathology 7, 447–463.Google Scholar
Spear, W. E., & Sugarman, A. (1984). Dimensions of internalized object relations in borderline and schizophrenic patients. Psychoanlaytic Psychology 1, 113–129.Google Scholar
Spiegel, D., & Cardena, E. (1991). Disintegrated experience: The dissociative disorders revisited. Journal of Abnormal Psychology 100, 366–378.Google Scholar
Spitz, R. (1956). The influence of the mother–child relationship, and its disturbances. In K. Soddy (Ed.), Mental health and infant development: Vol. I. Papers and discussions. Oxford: Basic Books.
Spitzer, R. L., Endicott, J., & Gibbon, M. (1979). Crossing the border into borderline personality and borderline schizophrenia. Archives of General Psychiatry 36, 17–24.Google Scholar
Sprock, J., Rader, T. J., Kendall, J. P., & Yoder, C. Y. (2000). Neuropsychological functioning in patients with borderline personality disorder. Journal of Clinical Psychology 56, 1587–1600.Google Scholar
Sroufe, L. A. (1989). Pathways to adaptation and maladjustment: Psychopathology as developmental deviation. In D. Cicchetti (Ed.), Rochester Symposium on Developmental Psychopathology (Vol. 1, pp. 13–40). Hillsdale, NJ: Erlbaum.
St. Clair, M. (2000). Object relations and self psychology: An introduction (3rd ed.). Belmont, CA: Brooks/Cole Publishing.
Stein, K. F. (1996). Affect instability in adults with a borderline personality disorder. Archives of Psychiatric Nursing 10, 32–40.Google Scholar
Stern, A. (1938). Psychoanalytic investigation and therapy in the borderline group of neuroses. Psychoanalytic Quarterly 7, 467–489.Google Scholar
Stolorow, R. D. (1995). An intersubjective view of self psychology. Psychoanalytic Dialogues 5, 393–399.Google Scholar
Stuart, J., Westen, D., Lohr, N. E., Benjamin, J., Becker, S., & Vorus, N. (1990). Object relations in borderlines, depressives, and normals: An examination of human responses on the Rorschach. Journal of Personality Assessment 55, 296–318.Google Scholar
Tolpin, L. H., Gunthert, K. C., Cohen, L. H., & O'Neill, S. C. (2004). Borderline personality features and instability of daily negative affect and self-esteem. Journal of Personality 72, 111–137.Google Scholar
Torgersen, S. (1980). The oral, obsessive, and hysterical personality syndromes: A study of hereditary and environmental factors by means of the twin method. Archives of General Psychiatry 37, 1272–1277.Google Scholar
Torgersen, S., Lygren, S., Oien, P. A., Skre, I., Onstad, S., Edvardsen, J., et al. (2000). A twin study of personality disorders. Comprehensive Psychiatry 41, 416–425.Google Scholar
Tyrer, P. J. (1996). Establishing the severity of personality disorder. American Journal of Psychiatry 153, 1593–1597.Google Scholar
van der Kolk, B. A., van der Hart, O., & Marmar, C. R. (1996). Dissociation and information processing in posttraumatic stress disorder. In B. A. van der Kolk & A. C. McFarlane (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 303–327). New York: Guilford Press.
van Ijzendoorn, M. H., Schuengel, C., & Bakermans–Kranenburg, M. J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology 11, 225–249.Google Scholar
Vollrath, M., Alnaes, R., & Torgersen, S. (1996). Coping in DSM-IV options personality disorders. Journal of Personality Disorders 10, 335–344.Google Scholar
Wachtel, P. (1977). Psychoanalysis and behavior therapy. New York: Basic Books.
Walsh, F. (1977). The family of the borderline patient. In R. R. Grinker & B. Werble (Eds.), The borderline patient. New York: Jason Aronson.
Westen, D. (1985). Self and society: Narcissism, collectivism, and the development of morals. New York: Cambridge University Press.
Westen, D. (1989). Are “primitive” object relations really preoedipal? American Journal of Orthopsychiatry 59, 331–345.Google Scholar
Westen, D. (1990a). The relations among narcissism, egocentrism, self-concept, and self-esteem: Experimental, clinical and theoretical considerations. Psychoanalysis and Contemporary Thought 13, 183–239.Google Scholar
Westen, D. (1990b). Towards a revised theory of borderline object relations: Contributions of empirical research. International Journal of Psycho-Analysis 71, 661–693.Google Scholar
Westen, D. (1991a). Clinical assessment of object relations using the TAT. Journal of Personality Assessment 56, 56–74.Google Scholar
Westen, D. (1991b). Cognitive–behavioral interventions in the psychoanalytic psychotherapy of borderline personality disorders. Clinical Psychology Review 11, 211–230.Google Scholar
Westen, D. (1991c). Social cognition and object relations. Psychological Bulletin 109, 429–455.Google Scholar
Westen, D. (1992). The cognitive self and the psychoanalytic self: Can we put our selves together? Psychological Inquiry 3, 1–13.Google Scholar
Westen, D. (1993). The self in borderline personality disorder: a psychodynamic perspective. In Z. V. Segal & S. J. Blatt (Eds.), The self in emotional distress (pp. 334–360). New York: Guilford Press.
Westen, D. (1994). Toward an integrative model of affect regulation: Applications to social-psychological research. Journal of Personality 62, 641–667.Google Scholar
Westen, D. (1995). A clinical-empirical model of personality: Life after the Mischelian ice age and the Neo-lithic era. Journal of Personality 63, 495–524.Google Scholar
Westen, D. (1996). A model and a method for uncovering the nomothetic from the idiographic: An alternative to the five-factor model? Journal of Research in Personality 30, 400–413.Google Scholar
Westen, D. (1998a). Case formulation and personality diagnosis: Two processes or one? In J. Barron (Ed.), Making diagnosis meaningful (pp. 111–138). Washington, DC: American Psychological Association Press.
Westen, D. (1998b). The scientific legacy of Sigmund Freud: Toward a psychodynamically informed psychological science. Psychological Bulletin 124, 333–371.Google Scholar
Westen, D. (2004). Clinical Diagnostic Interview. Unpublished manuscript, Emory University, available from www.psychsystems.net/lab.
Westen, D., Bradley, R., & Shedler, J. (2005). Refining the borderline construct: Diagnostic criteria and trait structure. Unpublished manuscript, Emory University.
Westen, D., & Cohen, R. P. (1993). The self in borderline personality disorder: A psychodynamic perspective. In Z. V. Segal & S. J. Blatt (Eds.), The self in emotional distress: Cognitive and psychodynamic perspectives (pp. 334–368). New York: Guilford Press.
Westen, D., Gabbard, G., & Blagov, P. (in press). Back to the future: Personality structure as a context for psychopathology. In R. F. Krueger & J. L. Tackett (Eds.), Personality and psychopathology: Building bridges. New York: Guilford Press.
Westen, D., & Heim, A. K. (2003). Disturbances of self and identity in personality disorders. In M. R. Leary & J. P. Tangney (Eds.), Handbook of self and identity (pp. 643–664). New York: Guilford Press.
Westen, D., & Heim, A. K. (2005). Impulsivity Questionnaire. Unpublished manuscript, Emory University, available from www.psychsystems.net/lab.
Westen, D., Lohr, N., Silk, K. R., Gold, L., & Kerber, K. (1990). Object relations and social cognition in borderlines, major depressives, and normals: A thematic apperception test analysis. Psychological Assessment: A Journal of Consulting and Clinical Psychology 2, 355–364.Google Scholar
Westen, D., Ludolph, P., Block, M. J., Wixom, J., & Wiss, F. C. (1990). Developmental history and object relations in psychiatrically disturbed adolescent girls. American Journal of Psychiatry 147, 1061–1068.Google Scholar
Westen, D., Ludolph, P., Lerner, H., Ruffins, S., & Wiss, F. C. (1990). Object relations in borderline adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 29, 338–348.Google Scholar
Westen, D., Ludolph, P., Misle, B., Ruffins, S., & Block, J. (1990). Physical and sexual abuse in adolescent girls with borderline personality disorder. American Journal of Orthopsychiatry 60, 55–66.Google Scholar
Westen, D., Moses, M. J., Silk, K. R., Lohr, N. E., Cohen, R., & Segal, H. (1992). Quality of depressive experience in borderline personality disorder and major depression: When depression is not just depression. Journal of Personality Disorders 6, 382–393.Google Scholar
Westen, D., & Muderrisoglu, S. (2003). Reliability and validity of personality disorder assessment using a systematic clinical interview: Evaluating an alternative to structured interviews. Journal of Personality Disorders 17, 350–368.Google Scholar
Westen, D., & Muderrisoglu, S. (in press). Clinical assessment of pathological personality traits. American Journal of Psychiatry.
Westen, D., Muderrisoglu, S., Fowler, C., Shedler, J., & Koren, D. (1997). Affect regulation and affective experience: Individual differences, group differences, and measurement using a Q-sort procedure. Journal of Consulting and Clinical Psychology 65, 429–439.Google Scholar
Westen, D., Nakash, O., Thomas, C., & Bradley, R. (in press). Clinical assessment of attachment patterns in adolescents and adults: Rediscovering attachment patterns in clinical practice. Journal of Consulting and Clinical Psychology.
Westen, D., & Shedler, J. (1999a). Revising and assessing Axis II, Part 1: Developing a clinically and empirically valid assessment method. American Journal of Psychiatry 156, 258–272.Google Scholar
Westen, D., & Shedler, J. (1999b). Revising and assessing Axis II, Part 2: Toward an empirically based and clinically useful classification of personality disorders. American Journal of Psychiatry 156, 273–285.Google Scholar
White, C. N., Gunderson, J. G., Zanarini, M. C., & Hudson, J. I. (2003). Family studies of borderline personality disorder: A review. Harvard Review of Psychiatry 11, 8–19.Google Scholar
Wilkinson–Ryan, T., & Westen, D. (2000). Identity disturbance in borderline personality disorder: An empirical investigation. American Journal of Psychiatry 157, 528–541.Google Scholar
Winnicott, D. W. (1953). Transitional objects and transitional phenomena: A study of the first not-me possession. International Journal of Psycho-Analysis 34, 89–97.Google Scholar
Wixom, J., Ludolph, P., & Westen, D. (1993). Quality of depression in borderline adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 32, 1172–1177.Google Scholar
Yen, S., Shea, M. T., Battle, C. L., Johnson, D. M., Zlotnick, C., Dolan–Sewell, R., et al. (2002). Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive–compulsive personality disorders: Findings from the collaborative longitudinal personality disorders study. The Journal of Nervous and Mental Disease 190, 510–518.Google Scholar
Yeomans, F. E. (2004). Transference-focused psychotherapy in borderline personality disorder. Psychiatric Annals 34, 449–454.Google Scholar
Young, D. W., & Gunderson, J. G. (1995). Family images of borderline adolescents. Psychiatry 58, 164–172.Google Scholar
Zanarini, M. (1997). Role of sexual abuse in the etiology of borderline personality disorder. Washington, DC: American Psychiatric Association.
Zanarini, M. C., Frankenburg, F. R., DeLuca, C. J., Hennen, J., Khera, G. S., & Gunderson, J. G. (1998). The pain of being borderline: Dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry 6, 201–207.Google Scholar
Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry 160, 274–283.Google Scholar
Zanarini, M. C., Frankenburg, F. R., Yong, L., Raviola, G., Reich, D., Hennen, J., et al. (2004). Borderline psychopathology in the first-degree relatives of borderline and Axis II comparison probands. Journal of Personality Disorders 18, 449–447.Google Scholar
Zanarini, M. C., Gunderson, J. G., & Frankenburg, F. R. (1990). Cognitive features of borderline personality disorder. American Journal of Psychiatry 147, 57–63.Google Scholar
Zanarini, M. C., Gunderson, J. G., Marino, M. F., Schwartz, E. O., & Frankenburg, F. R. (1989). Childhood experiences of borderline patients. Comprehensive Psychiatry 30, 18–25.Google Scholar
Zanarini, M. C., Yong, L., Frankenburg, F. R., Hennen, J., Reich, D., Marino, M. F., et al. (2002). Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. Journal of Nervous and Mental Disease 190, 381–387.Google Scholar
Zittel, C., Bradley, R., & Westen, D. (in press). Affect regulation in borderline personality disorder. Journal of Nervous and Mental Disease.
Zittel, C., & Westen, D. (2005). Borderline personality disorder as seen in clinical practice: Implications for DSM-V. American Journal of Psychiatry 162, 867–875.Google Scholar