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Book Forum: Diagnosis and Management of Specific Disorders   |    
A Developmental Model of Borderline Personality Disorder: Understanding Variations in Course and Outcome
Am J Psychiatry 2004;161:1318-a-1319. doi:10.1176/appi.ajp.161.7.1318-a
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New York, N.Y.

By Patricia Hoffman Judd, Ph.D., and Thomas H. McGlashan, M.D. Arlington, Va., American Psychiatric Publishing, 2003, 231 pp., $38.95 (paper).

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With the reader’s indulgence, I would like to begin this review with my final comment: this may well be the best book on borderline personality disorder you are likely to read.

The book is divided into three sections: the first on etiology, the second on case histories that illustrate variations in course and outcome, and the third on treatment. The integrated model the authors propose in their first chapter shows the interaction of genetic and environmental influences that may combine to create a disorganized pattern of attachment. Impulsivity and instability of mood may show up as temperament traits stemming in good measure from the genetic side. On the environmental side are maltreatment by parents (such as chronic verbal, physical, or sexual abuse) with its attendant stress and stress from other sources (such as early loss of key caretakers). All aspects of the mental triad—thought, feeling, and behavior—are adversely affected, leading to the special types of cognitive dysfunction, emotional dysregulation, and turbulent behavior that we place together under the heading of borderline personality disorder. The authors explain how the abnormally strong emotional reactions in borderline patients return "more slowly to baseline" (p. 31) and how their common complaint of "emptiness" is akin to an awareness that "something is missing." This may reflect a feeling of disconnectedness from others and from the pain they anticipate from interaction with others: a bad feeling, in other words, that is protecting the patient from still worse feelings of being overwhelmed by closeness with others.

The case histories in the second section are taken from the Chestnut Lodge Long-Term Follow-Up Study that Dr. McGlashan spearheaded in the late 1980s. The four histories constitute a graduated series from healthiest to most handicapped. These patients had been in intensive psychodynamic therapy for many months while at the Lodge, so in that sense they represent recipients of the kind of treatment that has become a lost art. They came from affluent families, so they are not "typical" of borderline patients in that respect. Nor was their treatment typical of what most such patients receive. Their early histories, however—the malignancy of their homes, the storminess of their life course, and eventual stabilization at either fairly good function or at continuing impairment—will be familiar to therapists who devote their energies to work with borderline patients, no matter what their main therapeutic schooling or style.

As for the treatment section, there is so much wisdom packed into its two chapters that I gave up underlining the gems with highlighter lest I underline the whole 63 pages. Space allows me to mention just a few:

Flexibility and creativity within an ethical and commonsense frame of reference not only are essential, but make the work challenging and rewarding. (p. 172)

Work with BPD patients requires a better than average ability to maintain consistent empathy, since the patient fails in this endeavor toward himself, the therapist, and important others. (p. 186)

Like the baby’s cry, talk of suicide becomes the patient’s primary mode of communicating distress. (p. 204)

Similarly, the borderline patient’s impaired emotional regulation and inability to describe feelings contributes to their overreliance on behavioral action patterns: they reenact rather than remember. (p. 205)

All relevant aspects of the disorder receive equally succinct and well-phrased explanations: self-mutilation, moral development and self-blame, paranoid reactions, dissociation, anxiety over improvement, secrecy, idealization and devaluation, and primitive defenses such as splitting.

Although the training and experience of the authors may reflect a largely psychodynamic tradition, their descriptions and advice will be of great value to therapists of all approaches and styles. The authors are candid enough to assert that "work with BPD patients is not for everyone," as they go on to enumerate some of the qualities in potential therapists that facilitate this work. One quality that helps, as they mention, is a "detective-like curiosity." As one who, like Dr. McGlashan, labored long and hard to trace large numbers of former borderline patients one or two decades after their discharge from the hospital, I can vouch for that. I hope this wonderful book of Judd and McGlashan will inspire others to carry on this work, learning along the way what makes borderline patients behave as they do, and what we can do to make them better.




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