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We suggest that the core features of borderline personality disorder (BPD) are the intense inner pain commonly reported by borderline patients and the awkward means they use to manage and express this pain. In this model, the pain has both affective and cognitive components. The awkward means of managing and expressing this pain are behavioral and interpersonal in nature. The etiology of these core features of BPD seems to lie in the interaction of a kindling event or events, which can be traumatic or normative in nature, and a vulnerable or hyperbolic temperament. The treatment and nosological implications of this model are discussed.
The place of borderline personality disorder (BPD) in psychiatric nosology has long been a point of contention. Stern (1938) was the first author to use the term borderline to describe a specific pathological condition; a condition that he thought had both neurotic and psychotic features.
Since that time, there have been six main conceptualizations of this term. The first of these conceptualizations is based on the work of Kernberg (1975). In this view, the term borderline is used to describe most serious forms of character pathology. The second conceptualization reflects the work of Gunderson (1984). In this view, the term borderline describes a specific form of personality disorder that can be distinguished from a substantial number of other axis II disorders, particularly those in the "odd" and "anxious" clusters of the DSM classification system. The third conceptualization, which flourished in the 1960s and 1970s, focused on the propensity of borderline patients to have transient psychotic or psychotic-like experiences. In this view, borderline personality was thought of as being a schizophrenia spectrum disorder (Wender, 1977). The fourth of these conceptualizations, which organized much of clinical care and empirical research in the 1980s, focused on the chronic dysphoria and affective lability of borderline patients. In this view, borderline personality was thought of as being an affective spectrum disorder (Aklskal, 1981; Stone, 1980).
Both the fifth and sixth theories of borderline psychopathology have arisen during the 1990s. Zanarini and her colleagues (1993) and Links, Heslegrave, and van Reekum (1999) have proposed that borderline personality disorder is best conceptualized as an impulse spectrum disorder (i.e., a disorder related to substance use disorders, antisocial personality disorder,...