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This paper is an important contribution to our understanding of a very difficult field. It is written so compactly and clearly that abstracting it does it an injustice. The first part of the paper deals with the definition of a borderline state. Knight then demonstrates the unreliability of some of our usual criteria in making the diagnosis. The narrow view of relationship to reality, the conception that neurosis and psychosis are mutually exclusive, and the too literal use of the levels of psychosexual development are all factors which make for difficulties in diagnosis. He points out that one has to regard the presenting clinical picture within the dynamics of the total personality structure. The superficial symptomatology may represent a holding operation in a forward position while the major portion of the ego has regressed far beyond this. The key to making the proper diagnosis and planning the appropriate therapy is based on appraising the total ego functioning of the individual.
Knight stresses the importance of detecting the impairment of some ego functions without being misled by the fact that others will be relatively intact. He indicates how the borderline patient usually presents signs in which one can observe that the normal ego functions of secondary process thinking are interfered with by eruptions from the primary process. Peculiarities of word usage, inappropriate affect, contamination of idioms, and the degree of ego syntonicity for psychotic intrusion are all valuable indicators of ego impairment. The face-to-face psychiatric interview provides a relatively structured situation in which the patient may be able to use cover-up methods to obscure his deeper pathology. The use of the free association interview has to be considered carefully because, although the borderline patient is more likely to reveal his illness in bolder relief with this method, at the same time it can also be a traumatic experience. Diagnostic psychological tests ap