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Psychiatrists and psychoanalysts treating borderline patients, face three problematic tasks. They must deal with the provocative and uncooperative behavior of their patients. They must try to provide interpretations that patients can accept and use. In many instances, they will find it useful or necessary to employ psychiatric drug therapy. For these purposes, it is useful to work with a theory of pathogenesis that will provide a basis for devising appropriate strategies. These few comments will suggest such a theory, and pursue its implications for treatment.
A sound theory should be based upon clinical data. One of the problems that we encounter in trying to delineate the characteristics of the borderline disorder is that different careful, skilled, and astute observers suggest different descriptions. Instead of treating this as an obstacle, I prefer to accept it as a significant finding. We must infer then, that the syndrome is characterized by variety and polymorphism. In other words, the specific qualities that are described in groups of patients who are designated as cases of borderline syndrome depend upon whether they are seen as outpatients or hospital patients, whether they are seen in private as opposed to community settings, in which socioeconomic group they belong, and the specifics of age, residence, and family background.
If we accept the description given in DSM-IIIR, we find that the quality cited as most characteristic of the condition is instability: instability of mood, of interpersonal relationships, and of self-image. Although missing from the DSM-IIIR description, I believe that most clinicians would agree that many different conditions may be exhibited by the borderline patient: depression, psychosis, neurosis, and other personality deficits. Among the specific phenomena,