Final Assignment

Running head: BORDERLINE PERSONALITY DISORDER
Borderline Personality Disorder – A Clinical Application of Theory
Amanda Weissman
Professor Maureen Marias
December 7th, 2015
University of Southern California

BORDERLINE PERSONALITY DISORDER 2
Introduction
This scholarly paper addresses the symptomology of borderline personality
disorder and provides an overview of the disorder. The paper proceeds to analyze the
etiology of borderline personality disorder through the lenses of Otto F. Kernberg’s
theoretical framework. A separate section on the neurobiological underpinning of
borderline personality disorder is also discussed. Diversity issues surrounding the
development and understanding of borderline personality disorder are addressed. Finally,
this paper concludes by analyzing an effective intervention for the treatment of borderline
personality disorder.
Overview of Borderline Personality Disorder
Borderline personality disorder is considered a common and serious mental
disorder that is characterized by specific patterns of behavior and symptomology. People
with borderline personality disorder show a consistent pattern of poor impulse control,
instability of affect regulation, unstable interpersonal relationships, and an inability to
solidify a self-image. A persistent issue of psychosocial impairment exacerbates a higher
mortality rate among people with borderline personality disorder; In fact, 10% of patients
with borderline personality disorder commit suicide. This is almost 50 times higher than
the general population (Lieb et al., 2004).
There are specific symptoms presented in people with borderline personality
disorder that are used to diagnose. The fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM–IV) classify borderline personality disorder as
presenting with a pervasive pattern of instability in identity, impulsivity, interpersonal
relationships, and affect (Leichsenring et al., 2011). Five or more the following features

need to be present to diagnose: “Frantic efforts to avoid real or imagined abandonment; A
pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation; Identity disturbances; Impulsivity in at
least two areas that are potentially self-damaging; Recurrent suicidal gestures, or threats
or self-mutilating behavior; Affective instability caused by a distinct reactivity of mood;
Chronic feelings of emptiness; Inappropriate intense anger or difficulty controlling anger;
Transient, stress-related paranoid ideation or sever dissociative symptoms” (Leichsenring
et al., 2011, pg. 75).
Borderline personality disorder should be viewed as a public health problem that
is debilitating to the people that suffer from the disorder and possibly detrimental to
society. Patients with borderline personality disorder utilize higher levels of services in
hospitals, outpatient care facilities, inpatient units, and emergency rooms. In fact,
borderline personality disorder patients account for 20% of psychiatric hospitalizations.
On top of these issues, borderline personality disorder patients are immensely difficult to
treat. Many patients refuse to take medication consistently, have erratic therapy
attendance, and pervasive non-compliance (Levy, 2005).
Otto F. Kernberg’s Model
Kernberg was a psychoanalyst who used various concepts from different theories
to help understand and treat various forms of disorders, primarily personality disorders.
Kernberg worked from a psychoanalytic, ego psychology, and objection relations
framework. He developed a model that primarily integrated three different forms of
conceptualizing human development, including the conceptualizations presented by the
works of Klein, Freud, Jacobson, and Mahler (Palombo, Bendicsen, & Koch, 2010).

Kernberg emphasized that there lies a fundamental premise of theories for
personality disorders. This fundamental premise says that observable behaviors, such as
personality traits, reflect identifiable and specific pathological attributes of underlying
pathological structures. Psychoanalytic theories, such as Kernberg’s model, allows for the
observation and understanding between relationships of pathological personality traits,
between various pathological behavior patterns as they fluctuate in treatment, and
between behaviors presented on the surface and underlying psychological structures
(Kernberg, 1995).
Kernberg constructed a developmental model that addressed the development of
personality disorders. The first major developmental task was to understand and clarify a
separation of self from object-images. Kernberg stressed that there needs to be a
boundary established or one cannot differentiate between one’s own experiences one’s
own mind, as well as the mind and experiences of others (Kernberg, 1967).
The second major task someone needs to move past is splitting, which Kernberg
viewed as a process that is represented in the separation-individuation process, a stage
coined by Mahler. Kernberg expressed that splitting is developed when an infant cannot
differentiate between feelings in the caregiver of good and bad and frustrating and
gratifying as affectively segregated. When this happens, the feelings of good and bad are
blended together and the infant inevitably retreats from combining representation of
others and self as good and bad (Kernberg, 1967).
The third major developmental task is to combine the representation of others,
such as the caregiver, with the good and bad self. The integration of the caregiver and
good and bad self would be more stable and at fuller capacity to tolerate fluctuations in

relationships with others. The child needs to obtain the knowledge that mother and father
(or the family dyad) can have a singular relationship that does not include the child, and
that the child can survive and thrive outside of the relationship (Kernberg, 1967).
Kernberg often worked with understanding and treating borderline personality
disorder. His model emphasized the connection between biological factors and
environment, stating that people with borderline personality disorder have a difficult time
integrating representations of themselves and others, due to factors such as negative
emotions and aggression. These unstable representations result in what Kernberg referred
to as partial representations. These unprocessed representations have the capability to
overwhelm positive representations of the self and others; therefore, the person
unconsciously keeps these representations split to protect the positive representations of
themselves and/or others. According to Kernberg, this split accounts for the lack of
identity a person feels with borderline personality disorder (Levy et al., 2006).
Kernberg used ego psychology to connect symptoms of borderline personality
disorder with aspects of ego weakness. A common symptom of borderline personality
disorder, lack of impulse control, is seen as part of a defensive characterological
formation. The lack of impulse control, which is present on the surface and connected to
ego weakness, may represent the presentation of the consciousness of a dissociated
identification system (Kernberg, 1967). Although Kernberg pulled his developmental
model from ego psychology concepts, he tied the idea of ego weakness into other
psychoanalytic concepts to help understand borderline personality disorder.
Another common symptom of people with borderline personality disorder is
affective instability. Affective instability is a common symptom of relationships that are

established at the earliest stages of life. These relationships inevitability shapes the rest of
someone’s life in how they process attachment with others. These processes lie at the
center of human experiences (Schore, & Schore, 2012). Kernberg was aware of this
concept and he understood this symptom by postulating that the lack of integrating an
internal image of self and others ultimately leads to affective instability. The split image
of self and others, which is due to the protection of positive representations, leads to
further affective instability by failing to provide a complete foundation to understand
oneself and others (Levy et al., 2006).
According to the approach developed by Kernberg, pathology of identity
formation is the hallmark of severe personality disorders, such as borderline personality
disorder. Kernberg believed that the disorder and most of its accompanying symptoms
were directly tied to the pathological structure referred to as “identity” in relations to
subjective experiences. If the identity formation corresponds with an unrealistic and
unstable sense of self and others, this reflects the predominance of pathological
aggression and defensive operations based on dissociation, known as splitting (Kernberg,
& Caligor, 1996).
Neurobiology of Borderline Personality Disorder
The application of neurobiological factors when looking at disorders and
disoriented processes is essential to understand specific needs for treatment and the
developments of disorders. Cozolino (2010) summed up the need by evidence that,
“…we are unable to engage in random actions because our behaviors are guided by
patterns established through previous learning to which we automatically return” (pg.
16). There is much research to support there are environmental causes that affect the

development of borderline personality disorder. Cozolino (2010) found that borderline
personality disorder manifests from early deficits in emotional regulation and disruptive
attachment relationships in early childhood (pg. 281). Recent neuroimaging studies have
shown that the notion of attachment history between a caregiver and an infant affects the
setting of a mental “switch”. This switch turns the brain’s mentalizing system from
controlled, planned, and organized cognitions to poorly sustained attention, narrowed,
and increased vigilance for attachment disruptions in processing, such as abandonment
and rejection (Fonagy, Luyten, & Strathearn, 2011). Also, there is research that supports
that patients with borderline personality disorder have parents that suffer from the same
disorder. This further perpetuates issues with attachment relationships due to the parent’s
instability. This leads the patient to have an early attachment that is emotionally
dysregulated, traumatic, and possibly life threatening (Cozolino, 2010).
Borderline patients have a pattern of showing chaotic experiences of infancy,
which in shown in the developmental neurobiological systems in the brain. The
amygdala, which is highly functional at birth, is the central spot of neural networks that is
involved in both attachment and fear. The dysfunctional and traumatic attachment
experiences cause a sympathetic fight-or-flight reaction to any indication of
abandonment. Also, due to this process, the levels of stress hormones are raised
(Cozolino, 2010).
The primary caregiver, such as a mother that suffers from borderline personality
disorder, greatly affects the child and potentially increases the likelihood of the child
developing the disorder. These children’s chronically intense emotions caused by a
chaotic relationship with their primary caregiver damage the hippocampus, which is

responsible for memory. This chronic stress causes an excess of a hormone that normally
helps the brain cope with stress – glucocorticoids. The hippocampus contains a high level
of glucocorticoid receptors. The high level of glucocorticoid receptors allows the
hippocampus to be susceptible to damage. This causes the mother to repeat destructive
behaviors with her child because she is unable to recall the intensely emotional events
that happened to her as a child; thus a vicious cycle is created with their child, potentially
affecting the child’s emotional and neurobiological development (Lawson, 2000).
Another component that plays an integral role in the positive development of
attachment are the neuropeptides, oxytocin and vasopressin. These two neuropeptides
activate the reward/attachment system and deactivate systems that are involved in
mediating social avoidance. Oxytocin facilitates positive social memories and activates a
positive emotional experience with other people. Also, oxytocin creates a sense of trust to
the intentions of others. Trust with a caregiver is found to be a key facet in human aspects
of attachment. A lack of oxytocin in a primary caregiver affects the sensitivity the
caregiver has to the child’s mental state, which in turn may cause a lack of secure
attachment between the child and the caregiver and a delayed development of minds on
part of the child (Fonagy, Luyten, & Strathearn, 2011). This validates the connection
between chaotic and disorganized attachment between a child and caregiver to the
potential development of borderline personality disorder.
Diversity in Borderline Personality Disorder
Diversity within the context of developing personality disorders, such as
borderline personality disorder, has to be taken into account when looking at the disorder
from a comprehensive viewpoint because diversity plays a role in most matters of

concern. In the respect of gender, there is no evidence that support that women suffer
from borderline personality disorder more than men (Leichsenring et al., 2011). Although
there are societal and cultural stigma on women and the development of self, many
feminists stress the importance of not studying women as the main caregiver that
influences the development of identity. Many theorists, especially during the early years
of research on the development of borderline personality disorder, failed to take into
account social class, race, sexual orientation, and ethnicity and how these factors may
have influenced the disorder (Berzoff, 2011). This can be found in the framework of
Kernberg, who believed that there was a difference between boys and girls with how
frequently disorders were developed based on Freudian psychosexual developmental
stages (Kernberg, 1967).
Certain cultural aspects growing up in the household, such as domestic violence
within a nuclear family context, affect the child’s development of borderline personality
disorder. Kernberg (1967) found that children later experience their parents as a “united
group”. If the mother is borderline and/or aggressive, there is a “contamination” of the
father’s image by the child and the child’s hatred for the mother is projected onto the
father as well. This is caused by the child’s inability to differentiate between the realistic
identities of objects. The excessive splitting mechanism by the child based on the
inability to differentiate causes a dangerous mother-father image. This image results in
chaotic, dangerous, and aggressive sexual relationships (pg. 679).
A well-supported correlation between borderline personality disorder and cultural
diversity is the impact of the socioeconomic status on the development of borderline
personality disorder. A wealth of research has shown the effects of low socioeconomic

class (low education level, low income, low status occupation) on physical and mental
health in adults and their offspring. Further studies have shown that many of the mental
health disorders common in people with a low socioeconomic status are personality
disorders, specifically borderline personality. Parental risk of developing borderline
personality disorder is increased by low socioeconomic statuses, which in turn elevates
the risk of their children developing borderline personality disorder. This is due to the
poor attachment between the borderline personality disorder caregiver and child, which
perpetuates throughout development (Cohen et al., 2008).
Sociocultural adaptations to low socioeconomic statuses may be a contributor to
the development of borderline personality disorder. Cohen et al (2008) found that some
adaptations acquired by caregivers who have low socioeconomic statuses are maladaptive
in nature and promote pronounced symptom expression, which gets passed down to their
offspring. Most of these adaptations include “expressed emotions”, such as negative
comments about their children that promote ongoing behavioral and emotional problems.
Another adaptation would be patterns of managing misbehavior, which is a risk in such
families and also promotes behavioral and emotional problems (pg. 12).
Treatment for Borderline Personality Disorder
There are various treatments that have been proposed and researched to address
and ameliorate symptoms of borderline personality disorder. A popular treatment that has
been specifically defined for borderline personality disorder is Transference Focused
Psychotherapy (TFP). Transference Focused Psychotherapy is a common treatment used
for borderline personality disorder. It is an approach based on an object relations

approach that Kernberg clinically theorized. Kernberg published a treatment manual for
this therapy (Clarkin et al., 2001).
Transference Focused Psychotherapy is based on the techniques of confrontation,
clarification, and the interpretation within the transference that is evolved between the
patient and the therapist (Clarkin et al., 2001). Its approach combines limit and boundary
setting and contracting with a focus on exploring the client’s internal world. The major
objectives of TFP is to help the client with behavioral control, increase appropriate self
reflection, increase a proper affect regulation, and promoting self integration. The
ultimate goal of TFP is to create a sense of self so that client can create satisfaction and
investment in relations with others and themselves. This also assists the client with
pursuing life goals and fulfilling a sense of purpose in their lives (Yeomans, Levy, &
Caligor, 2013). Understanding the sequences of events that happened as a child and
providing psychoeducation to the client about the self that got separated by the
incompleteness of attachment created with the caregiver help the client obtain the goals
of TFP (Kohut, & Wolf, 1978).
TFP is based on psychoanalytic techniques and concepts. These concepts and
techniques are organized and modified into a systematic approach as to best serve clients
with severe personality disorders. The main psychoanalytic derived from Kernberg’s
framework of understanding severe personality disorders and object relations theory is a
lack of identity integration. Consequently, this lack of identity integration manifests the
symptoms of borderline personality disorder and facilitates the lack of coherence with the
client’s understanding of themselves and others. The lack of identity integration, also
know as identity diffusion, relies on the defensive strategies, also know has splitting-

based defenses, that evokes dysregulated affect modulation, unstable interpersonal
relationships, and possibly cognitive distortion (Yeomans, Levy, & Caligor, 2013).
To help understand the psychoanalytic concepts in treating borderline personality
disorder, TFP considers the psychological structures presented in clients to be derived
from their attachment experiences with their caregivers as an infant. These interactions
are internalized as the client develops through out their lives, affecting many aspects of
their psychological development (Yeomans, Levy, & Caligor, 2013). These interactions
can include the caregiver invaliding the child’s emotional experiences and the caregivers
failing to understand the child’s mind. This results in the child not being able to think of
their own mind and that of others, or a creation of a “false self” (Levy et al., 2006).
Kernberg referred to the internalization of representations of others and self as
“personality organization”. The personality organization of the client leads the emptiness
the client feels which results in desperate attempts to relieve distress with impulsive
behaviors (Yeomans, Levy, & Caligor, 2013).
TFP is a highly structured, psychodynamic therapy. It involves twice weekly
sessions that address some of the client’s important psychological development. The first
stages of treatment include: understanding the relationship between biological
dispositions and social environment, to understand the core cognitive, behavioral, and
affective mechanisms involved in the maintenance and development of the disorder, and
to understand the pathways and developmental processes that the disorder takes. These
mechanisms of the treatment are conceptualized on two levels: what behaviors need is
being addressed for change in the treatment, such as self-esteem, emotional regulation,
emotional stability, and mindfulness, and what parts of the treatment will elicit change,

such as interpretation of transference, teaching of new skills, and provision of emotional
support (Levy et al., 2006).
TFP begins with a structured approach of the intervention that is understood by
certain concepts. The treatment begins with a “theoretically coherent” treatment approach
that includes treatment manuals, treatment contracts, and group supervision for therapists.
Also, treatment begins with confrontation such as honesty in pointing disparate
information, and interpretations of the transference in the here and now with the therapist
(Levy et al., 2006).
TFP highly structured approach has specific steps that followed by both the
patient and therapist. The therapist sets the frame of therapy with a contract that is signed
by both the therapist and the client. This contract enables a therapy room that is felt like a
safe haven for the client to express self and affect in regards to interactions and actions.
The client is then encouraged to observe the actions and interactions without reacting or
judging. By nonjudgmentally observing the actions and interactions, the client is able to
understand the behaviors by using clarification, confrontation, and interpretation. By
observing the actions and interactions in this manner, the client is able to increase
reflection, which increases progress towards integration. This integration increases
modulation of affects, which provides further reflection with increased contextualization
(Levy et al., 2006).
Conclusion
To conclude, this paper addressed an overview of borderline personality disorder
that addressed the prevalence of the disorder and common symptoms associated with the
disorder. Borderline personality disorder can be viewed through multiple theoretical

basis’s and this paper looks at Kernberg’s model of understanding borderline personality
disorder, which is based on a combination of object relations and psychoanalytic
concepts. Although Kernberg’s framework has amply contributed to the understanding of
the development of borderline personality disorder, the neurobiological underpinnings of
borderline personality disorder is explored and analyzed in this paper. Following the
theoretical analysis is a section discussing diversity within the context of borderline
personality, specifically gender and socioeconomic status. This paper concludes by
analyzing Transference Focused Psychotherapy in respects to treating borderline
personality disorder.

References:
Berzoff, J. (2011). Psychodynamic theory and gender. In J. Berzoff, L. Flanagan, & P.
Hertz (Eds.), Inside out and outside in (3rd ed., pp. 241-257). Lanham, MD:
Rowman & Littlefield.
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(6), 487-495.
Cohen, P., Chen, H., Gordon, K., Johnson, J., Brook, J., & Kasen, S. (2008).
Socioeconomic background and the developmental course of schizotypal and
borderline personality disorder symptoms. Development and psychopathology,
20(02), 633-650.
Cozolino, L. (2010). Building and rebuilding the brain: Psychotherapy and neuroscience.
In The neuroscience of psychotherapy (2nd ed., pp. 12-31). New York, NY: W.W.
Norton.
Cozolino, L. (2010). The neuroscience of psychotherapy: healing the social brain. New
York, NY: W.W. Norton & Company, Inc.
Fonagy, P., Luyten, P., & Strathearn, L. (2011). Borderline personality disorder,
mentalization, and the neurobiology of attachment. Infant Mental Health, 32(1),
47-69.
Kernberg, O. (1967). Borderline personality organization. Journal of the American
Psychoanalytic Association, 15(3), 641-685.

Kernberg, O. F. (1995). Object relations theory and clinical psychoanalysis. Jason
Aronson.
Kernberg, O. F., & Caligor, E. (1996). A psychoanalytic theory of personality disorders.
Major theories of personality disorder, 106-140.
Kohut, H., & Wolf, E. (1978). Disorders of the self and their treatment: An outline.
International Journal of Psychoanalysis, 59, 413-425
Lawson, C. (2000). Make-believe mothers. In Understanding the borderline mother (pp.
3-30). NY: Rowman & Littlefield.
Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline
personality disorder. The Lancet, 377(9759), 74-84.
Levy, K. N. (2005). The implications of attachment theory and research for
understanding borderline personality disorder. Development and
Psychopathology, 17(04), 959-986.
Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., &
Kernberg, O. F. (2006). Change in attachment patterns and reflective function in a
randomized control trial of transference-focused psychotherapy for borderline
personality disorder. Journal of consulting and clinical psychology, 74(6), 1027.
Levy, K. N., Clarkin, J. F., Yeomans, F. E., Scott, L. N., Wasserman, R. H., & Kernberg,
O. F. (2006). The mechanisms of change in the treatment of borderline
personality disorder with transference focused psychotherapy. Journal of clinical
psychology, 62(4), 481-501.
Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline
personality disorder. The Lancet, 364(9432), 453-461.

Palombo, J., Bendicsen, H., & Koch, B. (2010). Otto F. Kernberg (1928). In Guide to
psychoanalytic developmental theories (pp. 181-196). New York, NY: Springer
Publishers.
Schore, J., & Schore, A. (2012). Modern attachment theory: The central role of affect
regulation in development and treatment. In The science of the art of
psychotherapy (pp. 28-51). New York, NY: W.W. Norton.
Yeomans, F. E., Levy, K. N., & Caligor, E. (2013). Transference-focused psychotherapy.
Psychotherapy, 50(3), 449.

Final Assignment

More Related Content

What's hot

Viewers also liked

Similar to Final Assignment

Final Assignment