Borderline Personality Disorder (BPD) is a syndrome that begins in young adulthood, characterized by excessive impulsivity, imbalance in affect and interpersonal relationships, inability to perceive self and hypersensitivity to abandonment (APA, 2013)
Borderline personality disorder is a complex and serious mental disorder due to severe dysfunction and high risk of suicide. Although Stern (1938) used the term borderline among psychiatrists and mental health professionals long after its emergence in the psychoanalytic literature, it was only in 1980 that it entered DSM-III. Borderline personality disorder, which is 3 times more common in women than in men, occurs in 2% of the general population. The most distinctive features of borderline personality disorder are that they are aggressive, variable, inconsistent, depressed and prone to violence. Borderline personality disorder is a personality disorder with inconsistency and significant impulsivity in interpersonal relationships, self-perception and affect (Öztürk, 1997).
Borderline Personality Disorder (BPD) is a complex syndrome characterized by intense impulsivity, imbalance in mood and interpersonal relationships, intense anger and suicidal behavior, and self-confusion. The prevalence of BPD in the population was 5.9% and it was reported to be among the most common personality disorders encountered in clinical practice (Grant et al., 2008).
Borderline Personality Disorder in the psychoanalytic and psychodynamic approach
Among the causes of borderline personality disorder, psychodynamic factors such as insufficient support in the early childhood, lack of interest and discipline, or prevention of individualization, basic trust and autonomy due to excessive controls, and insufficient self-determination of limits of self are enounce. As with all other personality disorders, hereditary factors and traumatic events encountered in childhood (such as violence against children, sexual interventions, separation from parents) should be considered among the reasons. In the psychoanalytic perspective, borderline and narcissistic structures are treated as different ends of the same spectrum and have similar characteristics. Kohut’s narratives about the development of borderline personality traits derive from his views on narcissism. Kohut (1971) considers narcissism as a healthy developmental structure. Kohut thinks of narcissistic development in two lines. These two lines are ‘grandiose self’ and ‘idealized parental symbol’. These lines, which develop parallel to each other, provide the formation of children’s values, goals and ideals. Traumatic disappointment occurs when caregivers do not meet the child’s developmental needs. Thus, developmental pauses emerge. When traumatic disappointments occur on the line of idealized parental imagery, in the moments of anxiety during the adulthood, the individual is between a ‘power of energy source’ and ‘defensive grandiose self’. Since the sedative-calming properties of the caregiver are not internalized due to disappointments, when the integrity of the self is felt in danger, disintegration and borderline personality traits emerge (Kohut, 1971).
Klein mentions that the baby divides objects into good and bad and internalize them in self. Klein is the temporary object mother breast for the first period. The object that is there when needed, which feeds the baby, giving oral pleasure to the baby is a good breast, the breast who is not there is bad. This keep in the baby’s memory. According to the positive or negative reactions here, good or bad internalized self is formed (Alvarez, 1992). In the theory developed by Otto Kernberg, it has been one of the most clinically influential about BKB. The view of borderline pathology based on these object relations is important as it takes the lack of object consistency as a basis. The positive link of the child with the mother are sufficiently good that they should tolerate the integration of images of negative interaction with the mother. Kernberg argues that the nature of the object relations is often linked to the integration of identity, not only according to instantaneous integration, but also to the continuity of the concepts that he has created for the patient and others. Kernberg states that, as in interpersonal relationships, disturbances in the self are the result of inability to integrate the positive and negative representations of self and the other. As a result, the defense mechanism of splitting occurs. The perception that there will soon be a separation, that they will be excluded, or that the structure of the external world will collapse leads to a profound change in self-images, affections, thoughts and behaviors. These persons are very sensitive to environmental conditions (Kernberg, 1967). People with borderline personality disorder may have multiple changes in their value judgments and their passion for their work. There may be a number of changes in their views and plans regarding their work, their sexual identity, their value judgments and their chosen friends (Kernberg, 1976). Kernberg (1967) explained the etiology of border personality organization based on Mahler’s (1952) developmental schema. This period begins with the completion of the separation of self design from object design in “good” and “bad” self-object designs. This shows that the boundaries of the self and the non-self are determined. That is, the separation of self and object components means the establishment of ego boundaries. “Good” and “bad” designs are separated by splitting, yet there is no concept of an close-knit self or integrated object. The period ends with the integration of “good” and “bad” self designs into a “whole object concept of object. In this period, hanging and regression to the period determines the borderline personality organization (Akt. Stone, 1986). Kernberg stated that patients with borderline personality disorder had successfully passed the second period, which Mahler (1952) described as the symbiotic phase, that they could clearly distinguish between the self and the object, but that they were stuck in the third phase, Mahler’s words. Kernberg (1967) pointed out the lower stage of rapprochement, which Mahler described as a chronological location of this developmental crisis between the 16th and 30th months. At this stage, the child is alert to the potential for his mother’s disappearance and sometimes shows an extreme interest in his whereabouts. From this developmental point of view, it can be said that borderline patients behave as if they were relieved of the distress of an early infantile crisis, fearing a separation threat that would result in their mother’s abandonment and disappearance. In the adult form of this childhood crisis, individuals cannot tolerate being alone and are afraid of being abandoned by those who are important to them. Borderline patients may experience extreme anxiety when faced with separation from their parents or other caring figures (Baykız, 2003).
Kernberg thought that there was an interruption in the child’s development when he was separated from the mother figure while he was in the separation-individuation process. According to Kernberg, projective identification, which defines the splitting of self-images and then being reflected to other people for inspection purposes, is one of the primitive defenses commonly used in borderline personality organization. Splitting as a defense mechanism is the rejection of the displacement of a fantasy that fulfills the desires of the whole image of perception, and the suppression of mental content rather than consciousness, because the content cannot connect with an old memory.
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Margaret Mahler states that people with BPD have difficulty process of separation and individualization with others. In this phase, it connects to the image of a ‘good enough mother, both satisfying the path of pleasure and causing disruptions in the process of achieving this pleasure. If the mother who causes disruptions cannot solve her own conflict of autonomy and independence, she can prevent this effort of her own child or cause the child to overwhelm if she directs the attention she can not see to her own child. It may also be that there is no one providing both saturation and an obstruction (Geçtan, 1997)
Borderline Personality Disorder in the Cognitive Behavioral Theory
According to Beck’s Cognitive Behavioral Theory, the individual move on important role in both behavior and emotional reactions by influencing the perception of basic assumptions about other people and life and the interpretation of events. In individuals with a diagnosis of BPD, three basic assumptions are of central importance and it is stated that this pathology is shaped by three basic assumptions. These assumptions; ‘The world is full of dangers and bad intentions’, ‘I am weak and vulnerable’ and ‘I am unacceptable by birth an. The fact that the individual believes that the world is full of danger and perceives himself powerless has important consequences affecting the whole life. This leads to the conclusion that it is always dangerous to leave alertness and attention, to take risks, to reveal weakness, to be uncontrolled. Therefore, there is a constant tension and anxiety, sensitivity to danger signs, cautiousness in interpersonal relations, and discomfort from emotions that are difficult to control. Such avoidance behaviors nourish weakness and vulnerability and cause the ‘awake defensive’ attitude to continue. According to this theory, individuals with BPD diagnosis or characteristics think that they are unaided without a source of trust in a hostile world. Therefore, they switch between loneliness and dependence without fully trusting anyone. In addition, sudden emotional changes and dramatic behaviors occur with thought distortions (commonly in black and white style) (Beck, 1995; Beck ve Freeman, 1990).
The psychodynamic approach aims to emphasize self-discomfort related to attachment and interpersonal difficulties as the primary treatment goal. First, a well-established relationship with the patient and therapist should be founded. The therapeutic bond is important for the client who cannot fully trust and rely on the other person. If we look at the bond, unconditional feelings that the child cannot see and combine from the family in the early period and their inability to adopt them and experience them by the therapist may be better for the patient. The patient does not experience at least the fear of insecurity and abandonment during therapy, he / she may try this relationship experience in his/her private life. The person showing the borderline organization cannot see other people as beings that are a mixture of positive and negative qualities. Since he evaluates people in one or the other pole in absolute terms, their ability to feel the lives in their inner world is also significantly hindered. Exaggerating or completely discrediting the same person from one day to another creates very difficult situations for those who are related with the person. important point in the treatment process is the good transfer of projective identification and division by the patient to the therapist. It is likely to advance the treatment process to ensure spiritual maturation, to identify obstacles in developmental periods, to integrate fragmented personality structuring and object designs, to reduce high aggression, to increase one’s defense mechanisms to a more ripe level.
Cognitive behavioral theory, which shows cognitive deficits to the patient in borderline treatment and reflects that this is not true, is inadequate in this regard compared to psychodynamic theory. Psychodynamic approach, aims to solve these problems by gathering these distorted internalized objects by stroke to the main cause of the problem. A person who could harm him/her cannot apply the tasks given in the CBT approach in a healthy way.
Various studies have shown that there is a close relationship between affective disorders and borderline. Some researchers believe that the symptoms expressed by borderline patients as meaninglessness, loneliness or emptiness are actually symptoms of depression. According to them, the difference between borderline depression and internal depression arises from the fact that aggression is experienced at the consciousness level (Gunderson and Zanarini, 1987). The patient’s mood may change within hours and rarely remain unchanged for several days or longer. This symptom is also seen in mood disorders such as dysthymia, cyclothymia, hypomania and bipolar disorder (Akiskal, 1981).
Transfer oriented therapy is a structured form of psychodynamic therapy based on Otto Kernberg’s object relations model. At the heart of Kernberg’s model are the mental representations obtained by internalizing the attachment relationships with the primary caregiver. According to Kernberg, the degree of differentiation and unification of these representations of self and others constitutes personality organization along with emotional values. The main aim of transfer-oriented therapy is to develop personality and object representations, to mature primitive defense mechanisms, and to dissolve the more positive identity spread of representation in the patient’s inner world. In this treatment, focusing on transference is the primary tool for transforming primitive object representations (ie, splitting) into more advanced ones.