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The conceptualization of borderline personality disorder (BPD) has changed significantly over the last 80 years. What emerged from the psychoanalytic literature and remained an exclusively psychoanalytic construct for its first 50 years has metamorphosed into a burgeoning area of empirical research from multiple standpoints. Our goal in this article is to offer a contemporary description of BPD informed by both psychoanalytic clinical theory and observation and by the available research, focusing on the phenomenology, etiology, and treatment of the disorder. We argue that an empirically informed psychodynamic approach is central understanding BPD from a contemporary developmental psychopathology perspective.
Before beginning, we address briefly the question of why one might think about BPD from a psychodynamic perspective. It is an irony of our times that psychodynamic approaches are disappearing from the academic and therapeutic landscapes just as empirical research has begun to corroborate some of their most important postulates, for example, about the ubiquity of unconscious processes, including implicit affective and motivational processes; the importance of early attachment relationships for subsequent development and psychopathology; the role of personality as a diathesis for many disorders (and the source of much of their comorbidity); and the role of the therapeutic relationship in effecting change in psychotherapy (Westen, 1998b). What dynamic perspectives on BPD have assumed from the start is perhaps the core postulate that unites theory and research in developmental psychopathology: that psychopathology needs to be understood in its developmental context. Nowhere is this postulate more important than in BPD, a malady whose core deficits and dysfunctions are in domains of representation (of the self, others, and relationships) and emotion regulation that normally emerge in the context of nurturant attachment relationships and stable family systems. What perhaps continues most to distinguish dynamic approaches to treatment is the use of developmental models in thinking about what needs to be accomplished in helping patients with BPD change. As we shall see, clinical observers framed some important hypotheses about the nature, etiology, and treatment of BPD that have turned out to be not only prescient but important in understanding and treating borderline patients.
The Nature and Phenomenology of BPD
Like the construct of psychopathy (Cleckley, 1941), the construct of BPD emerged from the observation of patients who seemed on the surface...