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Borderline Personality Disorder

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Contents
Abstract ................................................................................................................................. 4
History of borderline personality disorder ............................................................................ 5
Characteristics of borderline patients .................................................................................... 7
Etiology ................................................................................................................................. 8
Psychodynamic approach .................................................................................................. 8
Cognitive-social theories ................................................................................................. 10
Genetic and biological factors ......................................................................................... 10
Environmental factors ..................................................................................................... 11
Stress diathesis model ..................................................................................................... 11
Borderline personality disorders and other psychological disorders .................................. 12
Borderline and Posttraumatic stress disorder .................................................................. 12
Borderline and antisocial personality disorder ................................................................ 12
Impulsivity .................................................................................................................. 12
Affective instability ..................................................................................................... 13
Cognitive symptoms .................................................................................................... 13
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Psychotherapeutic treatment ............................................................................................... 14
Cognitive-behavioural treatment ..................................................................................... 14
Psychodynamic therapy .................................................................................................. 15
Borderline personality disorder across cultures .................................................................. 16
Conclusion ........................................................................................................................... 17
References ........................................................................................................................... 19














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Abstract
Criteria for diagnosing borderline personality disorders have been changing ever since the
term has been introduced in psychological theory and practice. It is often discussed its
relation to other personality disorders as well as its etiology. As the prevalence of this
disorder grew bigger, the need for deeper understanding the phenomenology, etiology and
implications for treatment of borderline personality disorder emerged. Dominant explanations
of the nature of borderline personality disorder originated from psychodynamic theories
which emphasized early development as an essential factor for the development of this
disorder. Other theories and perspectives on the causes of borderline personality disorder
have emerged, but there is still a question of effective treatment of this disorder. On the other
hand, there has been growing interest of researching borderline personality concept in
different cultures and validating the results of American and European studies on Eastern
cultures. This paper had the goal to present the development of the concept of borderline
personality disorder, to determine its characteristics in terms of diagnosis and
phenomenology, to give perspective on its causes and treatment and to present findings of
studies in Asia regarding borderline personality disorders.








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History of borderline personality disorder
The history of personality categorization can be traced to the early Greeks and character
writing originating in Athens. These depictions of characters were sketches that described
common types of characters, emphasising a dominant trait as a way of explaining a flaw or
foible of an individual. In 4
th
century B. C., Hippocrates identified four basic temperaments
associating each with the dominant body fluid. Centuries later, Galen associated
Hippocratess choleric temperament with a tendency towards irascibility, sanguine
temperament with optimism, melancholic with sadness and phlegmatic temperament with
apathetic disposition (Millon & Davis, 1995).
In 18
th
century, Gall argued that intensity and character of thoughts and emotion correlate
with variations in the size and shape of the brain or its encasement, the cranium. Pinel
observed patients who engaged in impulsive and self-damaging acts although their reasoning
abilities were unimpaired. He referred to it as la folie raisonnante. He described cases of
insanity without delirium and was the first to recognize that madness does not signify the
presence of a deficit in reasoning powers. Rush depicted individuals with lucidity of thoughts
and socially deranged behaviours. (Millon & Davis, 1995).
In early 20
th
century, people with personality disorders were viewed as, as Scneider
described them, a set of psychopathic personalities which co-occurred with other psychiatric
disorders (Oldham, 2009). Kraepelin formulated a number of subaffective personality
conditions, similar to current borderline personality disorder; those included excitable
personality, mixture of fundamental states, extraordinarily great fluctuations in emotional
equilibrium; they are easily moved by their experiences, their mood is a subject to frequent
change, give expression to thoughts of suicide; they are mostly very distractible and unsteady
in their endeavours, they make sudden resolves and carry them out on the spot, run off
abruptly, go abruptly, enter a cloister (Kraepelin, 1921, pp. 130-131, in Krawitz & Jackson,
2008).
The term borderline personality disorder was first introduced in 1930s by Adolph Stern
(1938, in Gunderson & Links, 2008) in order to identify groups of clients who did not fit into
usual categorization at the time. People were diagnosed as either neurotic, involving what we
now refer to as anxiety and depressive disorders, or psychotic, involving bipolar disorder and
schizophrenia, as we now refer them. In spite of the dominant categories of neurotic and
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psychotic symptoms, clinicians recognized many patients suffering from severe emotional
distress or experiencing social or occupational impairment due to the symptoms they
experienced. Their pathology did not involve frank psychosis or other syndromes
characterized with depressive episodes, persistent anxiety or dementia (Oldham, 2009).
Patients from this uncategorized group expressed symptoms of neurotic category, but did not
respond to the usual treatment of neurotic disorders at the time. They had occasional
psychotic or psychotic-like experiences, but they were not sufficient to categorize them into
psychotic category. Patients with most severe and disabling symptoms were referred to long-
term inpatient treatment or outpatient psychoanalysis or psychoanalytically oriented
psychotherapy (Oldham, 2009).
From the context of World War II the need for standardized psychiatric diagnosis
emerged. War department developed a document labelled Technical Bulletin 203,
representing a psychoanalytically oriented system of terminology for classifying mental
illness precipitated by stress. Together with APA experts, diagnostic manual for psychiatric
diagnoses was developed. (Oldham, 2009). It was the framework for the first edition of DSM.
DSM I presented a general view on personality disorders which persisted to the presence.
Personality behaviours were viewed as more or less permanent patterns of behaviour and
human interaction, established b early adulthood and unlikely to change throughout the life
cycle (Oldham, 2009, p. 6).
Borderline personality disorder first appeared in DSM III manual in 1980s, together with
narcissistic personality disorder. The criteria for defining borderline personality disorder
emphasised emotional dysregulation, unstable interpersonal relationships and loss of
impulse control more than cognitive distortions and marginal reality testing, which were
more characteristic of schizotypal personality disorder (Oldham, 2009, p. 8). Grinker et al.
(1968, in Gunderson & Links, 2008, p. 3) argued that borderline psychopathology is a by
product of social changes during the twentieth century. The earlier burdens of manual labour
and the earlier restrictions of travel, communication and leisure time may have offered the
structure, survival activities, and monitors that silently kept such psychopathology in check.
DSM IV finally defined nine criteria for borderline personality disorder diagnosis. They
include: a) disturbed relationships; 2) abandonment fears; 3) chronic feelings of emptiness; 4)
affective instability; 5) inappropriate, intense anger or lack of control of anger; 6) impulsivity
in at least two potential self-damaging activities; 7) suicidal or self-mutilating behaviour; 8)
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identity disturbance; 9) transient, stress related paranoid ideation or severe dissociation
symptoms (Gunderson & Links, 2008).
There is a growing debate about the appropriateness of use of categorical or dimensional
system of classifications, relevant criteria for diagnosing it and its association to other
personality disorders.
Characteristics of borderline patients
Borderline patients lack of self-soothing capacities derived from the ability of a child to
internalize nurturing caregivers and sooth themselves even when the caregivers are not
present. Lack of those abilities creates a tendency of evoking intense feelings of loneliness
and panic through the life of borderline individual.
Herman (1997, in Braid, 2008) describes the relationships of individuals who survived
severe childhood abuse. These relationships involve intense periods of searching for intimacy
and idealization of the other person, alternating with periods of angry withdrawal and
denigration. They are driven by the need for care and fear of abandonment and betrail. When
disappointed, they furiously denigrate the person they idealized and adored. Even minor
disappointments tend to evoke childhood experiences of neglect and cruelty (Braid, 2008).
The lack of evocative memory, the ability to recall memories of comforting and secure love
relationship leaves them dependent on real care and assurance from others. The experience of
abandonment can become so intense that the patient feels that they cannot survive without the
relationship (Judd & McGlashan, 2008).
Characteristic assumptions of borderline patients involve the idea that people are
dangerous and malignant figures, the idea of them being powerless and vulnerable and the
idea that they are inherently bad and unacceptable to both self and others. Following these
ideas, patient does not dare to trust others, and themselves cannot be trusted either (Arntz,
1993)..
Borderline patients are obsessed with the potential rejection or abandonment; they are in
need to be with others in order to be able to perceive themselves. They use others as mirrors
of their self-perception (Dobbert, 2007, p. 66). Persons afflicted with borderline personality
disorder are prone to perceive relationships with others as intimate very early. Their
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relationships are unstable due to borderliners delusional beliefs of enduring love or
friendship which ends as soon as their expectations are not fulfilled. Borderline personality
disorder is characterized with identity disturbances which might be expressed through radical
changes in styles of dressing, attitudes, social preferences and hobbies (Dobbert, 2007). Their
thinking style is, one-dimensional and childish, and the evaluations black-and-white due to
undeveloped cognitive powers (Arntz, 1993). When borderline individuals feel deprived or
betrayed they experience anger and anxiety that activate coercive and controlling attachment
behaviours (Judd & McGlashan, 2008, p. 189). They employ splitting mechanisms during
these states which prevent them composing opposite feelings and thoughts about the other
person.
Etiology
Psychodynamic approach
Psychoanalytic theories were the first to generate a concept of personality disorder.
Personality disorders began to draw attention of psychoanalysis because of their resistance to
psychoanalytic treatment and explanation methods. Freuds view on psychological problems
in terms of conflict and defence mechanisms was not suitable enough to explain the origin of
personality disorders and most analytic theorists have turned to ego psychology.
Ego psychologists describe personality disorders as states of various deficits in
functioning, such as poor impulse control and affect regulation and deficits in the capacity for
self-reflection. Stern (1938, in Porder, 1993) suggested that failures in early mothering are
related to the pathological narcissism of the borderline individual, providing a soil for the
other pathology to emerge. Disturbances in early childhood are causes of anxiety, idealisation
tendencies and childlike self-image. He described features of borderline personality disorders
which involved narcissism created as a self-perserving function, leading to psychotic-like
transference, lack of maternal affection, parental quarrels, outbursts direct at child, early
divorce, separation or desertion, cruelty, brutality and neglect by parents over many years
duration (Baird, 2008). Greenacre (1971, in Porder, 1993) argued that trauma in the first two
years of life could have interfered with ego development. Mahler and Furer (1968) suggested
that there was a period of vulnerability in early childhood the separation-individuation
phase; disturbances in this period could be related to borderline phenomena. Mothers
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resistance towards individuation created pathological regressive bond between borderline
individuals and their mothers (Porder, 1993).
Otto Kernberg (1975a, 1984, 1996, in Heim & Western, 2009) developed a theory of
personality organisation in which he proposed a continuum from chronically psychotic levels
of functioning, through borderline functioning as severe personality disorders, through
neurotic to normal functioning. What distinguishes individuals with borderline disorders from
the ones with neurotic disorders is their regulation of emotions through immature, reality-
distorting defences such as denial and projection (primitive defences), and their difficulties
in forming mature multifaceted representations of themselves and significant others (identity
diffusion) (Heim & Western, 2009).
Developmentalists suggest that borderline pathology is a result of defect in development
of early object relations. Internalization of hostile, abusive, critical, inconsistent or neglectful
parents creates children vulnerable to fears of abandonment, self-hatred and tendency to treat
themselves as their parents treated them (Heim & Western, 2009). Winnicott (1953/1958,
1960/1965) developed concepts which contributed in later treatment of borderline patients.
These concepts include transitional objects and transitional phenomena and the holding
environment. Transitional object and transitional phenomena concept refers to the childs
ability to imagine me/not me. This concept had implications on relation between patient
and therapist and it is considered that it represents a developmental basis for the ability of the
patient to use transference during therapy. The holding environment represents a safe and
protected place where the child can be alone or alone with others, a space that usually good
mother provides (Porder, 1993).
Developmentalists consider that borderline occurs early in childhood, starting with
extreme anxiety and primitive defences that protect the integrity of ego. Object relationships
are immature and incapable of maintaining stable sense of self or identity. The border
between self and the outside world is blurry and the perception of reality damaged (Porder,
1993).
There is a high correlation between the level of borderline psychopathology and the
severity of childhood trauma (Baird, 2008).
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Cognitive-social theories
Cognitive-social theorists believe that learning is the basis of personality and that
personality dispositions are shaped by their consequences. Environmental influences and
individuals information processing about self and world are the basis for building personality
(Heim & Western, 2009).
Personality disorders are interpreted in light of the schemas, expectancies, goals, skills,
competencies and self-regulation. Dysfunctional schemas lead patients with personality
disorders to misinterpreting information, encoding information in biased ways or view
themselves as bad or incompetent. Borderline patients are prone to misinterpreting peoples
intentions and have troubles with self-regulation, including specific skills. According to
Linehan, emotion dysregulation is the essential feature of borderline personality disorder.
Emotion dysregulation include difficulties in a) inhibiting inappropriate behaviour related to
intense affect, b) organizing oneself to meet behavioural goals, 3) regulating physiological
arousal associated with intense emotional arousal and 4) refocusing attention when
emotionally stimulated. These difficulties lead to disturbances in interpersonal relationships
and in developing stable sense of identity (Heim & Western, 2009).

Genetic and biological factors
Past two decades, genetic disposition for borderline personality disorder has been studied.
In one twin study, the heritability of 0.69 for borderline personality disorder was found and
overall heritability of 0.60 for DSM IV Cluster B personality disorders. The heredity of the
disorder expresses itself through traits of affective instability, impulsivity, self-harm and
identity problems. Case histories also provide evidence of presence of Cluster B disorders
and traits in patients families (Judd & McGlashan, 2008).
Andrulonis et al. (1980, in Judd & McGlashan, 2008) found wide range of problems with
brain functioning in borderline patients, including episodic dyscontrol, neurological
dysfunction, epilepsy, minimal brain dysfunction and learning disabilities. Study of Kimble et
al. (1997, in Judd & McGlashan, 2008, p. 9) found neurological vulnerability of borderline
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patients in 87,5% , with a high occurrence of childhood speech/language disturbance,
learning disabilities, ADHD and reported complications of birth and pregnancy.
Affect and impulse dysregulation are attributed to altered functioning of central
serotonergic system, while suicide and self-injurious behaviour are attributed to lower levels
of 5-HT and abnormalities in dopaminergic system. These behaviour patterns were
established to correlate with severe traumatic stress in childhood, such as physical and sexual
abuse (Judd & McGlashan, 2008).
Environmental factors
There is an increase in prevalence of parasuicide and completed suicide in youth
diagnosed with borderline personality disorder. This fact could be interpreted by the
breakdown in traditional structures which guides the development of young people.
Impulsive disorders such as borderline, are particularly responsive to social context and the
structure and limits it provides. Traditional societies are defined as having high social
cohesion, fixed social roles and high interpersonal continuity which provide framework for
building sense of identity and the feeling of belonging (Paris, 2007). Individuals with
borderline personality disorders act impulsively as a way to handle their emotional
dysregulation. Linehan (1993, Paris, 2007) suggested that impulsive behaviours decrease in
patients with borderline personality disorder in the conditions with social support.
Stress diathesis model
In stress diathesis model, every category of mental disorder is associated with certain
genetic vulnerability. Genes shape individuals vulnerability, temperament and traits. Traits
become maladaptive in certain environmental conditions, meaning that diathesis becomes
apparent when uncovered by stressors. The interaction between diathesis and stressors is
bidirectional: genetic predispositions determine the way people react on the stimuli in their
environment, while the stressors and environmental factors in general determine what genetic
dispositions would be uncovered
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Borderline personality disorders and other psychological disorders
Borderline and post-traumatic stress disorder
It is often discussed whether borderline personality disorder and post-traumatic stress
disorder are synonymous because of the central role of the trauma in their development.
These disorders often occur together and have similar symptoms. However, there are certain
distinctions. Individuals with PTSD have relatively accurate memories of the traumatic event,
while borderline individuals have experienced trauma in early age when such memories
might have not survived. Trauma in early childhood may induce symptoms similar to those in
PTSD. However, these symptoms become transformed and incorporated into the personality
structure because of the childs inability to process and integrate information (Judd &
McGlashan, 2008).
Borderline and antisocial personality disorder
Applying cluster analysis to the symptoms of borderline personality disorder, Hurt et al.
(Paris, 1997) found three underlying dimensions: impulsivity, affective instability and
cognitive deficits. Livesley and Schroeder (Paris, 1997) also found the same three dimensions
including the fourth: identity diffusion.
Impulsivity
There is a significant overlap between impulsivity of patients with borderline and
antisocial personality disorder. Borderline individuals sometimes demonstrate petty theft,
substance abuse, dangerous driving or high risk sexual activities as primitive defences from
the intense feelings of anxiety. Those characteristics are defining features of antisocial
personality disorder. However, impulsivity has different background within these disorders.
Antisocial patients use people and discard them after they no longer need them, while
borderline patients tend to discard others after, as they perceive it, being betrayed and
disappointed by them. Antisocial patients exploit others, while borderline patients tend to be
exploited. Antisocial patients lack of concern for their victims, while borderline patients are
likely to comply with others (Paris, 1997).
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Affective instability
Borderline patients suffer from continuous dysphoria which makes them highly responsive
to their environment. They use impulsive actions as distraction from dysphoric emotions.
Antisocial patients express dysphoric mood when they are prevented from acting out (Paris,
1997). Both antisocial and borderline patients seem to use their maladaptive behavioural
patterns to avoid dysphoric emotions.
Cognitive symptoms
Borderline and antisocial personality disorder differ in symptoms that involve auditory
hallucinations, subdelusional paranoid trends, mycropsychoses or chronic depersonalization
and derealisation experiences. Although not systematically studied on antisocial patients, it is
considered that these symptoms are used to help them escape from criminal charges (Paris,
1997).

According to Paris (2000) gender influence provides the explanation of differences
between types of personality disorders from cluster B. Borderline and antisocial disorder
have common family histories and impulsivity as phenomenological distinction. Paris argues
that both borderline and antisocial disorder could represent alternate versions of the same trait
pathology with symptoms specific to gender (Paris, 2000, p. 79). Exploitive behaviour and
aggressivity typical for antisocial disorder is more common in men, while the aggression
against self and self-destructive behaviour typical for borderline patients is more common in
women. Patients in child psychiatric are usually boys, mainly because of their behavioural
disruptions that lead to referral. Paris argues that is likely that girls experience the same
intensity of distress, but tend to develop more internalizing then externalizing symptoms.
Boys are more likely to develop antisocial behaviour at earlier age, while girls are more likely
to develop borderline personality disorder later in life, which would explain the dominance of
male patients on child psychiatric. Both boys and girls have history of conduct disorder
during childhood (Paris, 2000).

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Psychotherapeutic treatment
Cognitive-behavioural treatment
Perhaps the most difficult thing in treating borderline patients is constructing a working
relationship. The contact between the patient and the therapist is dominated by ambivalent
feelings, including a desire for help and acceptance in one hand and the feeling of being hurt
and rejected. Therefore, it is hard to determine and follow the goals and methods of the
therapy. The patients inability to trust others can create severe difficulties for the therapy
process. The therapist might feel discouraged, but they need to realize that the patients
behaviour is the reflection of their problem. Trust cannot be enforced by discussion or
convincing the patient; empathetic reation to the problem, consistent and congruent behaviour
are crucial in developing trusting relationship (Arntz, 1993).
Emphasis in cognitive-behavioural therapy is on banishing symptoms or making them
more bearable. In long-term, the goal is to cope with emotions more adequately, modify
thinking errors, and in the end, to process trauma and change their core schemas. Modifying
thinking patterns can be accomplished by introducing standard cognitive techniques, such as
cognitive diary. Socratic questioning can be used for deriving information and moving the
patient to the desired goal, but without triggering intense emotional responses before the
patient is ready (Fusco & Apsche, 2005). Changing core schemas and processing trauma
cannot be done easily. Therapist needs to clarify the context of the trauma and to approach
patients memories and emotions slowly, with caution in order to help the patient to release
their fears and at the same time maintain the control over their experiences (Arntz, 1993).
Layden et al. (1993, in Fusco & Apsche, 2005) described characteristic maladaptive
schema in borderline patients involving dependence, lack of individuation, emotional
deprivation, abandonment, mistrust, unlovability and incompetence. These schemas produce
cognitive distortions such as dichotomous thinking and catastrophizing and lead to significant
dysfunction of the patient. Techniques such as Cognitive conceptualization diagram and the
Incident chart are used for identifying schemas and organizing their impact on patients
functioning (Fusco & Apsche, 2005).
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Psychodynamic therapy
When treating patients with borderline personality disorder, therapists deal with the
challenge of handling patients struggle with interpersonal closeness and resistance which
might be expressed through acting out, intense negative affects and regressive and self-
destructive behaviours (Waldinger & Gunderson, 1989). It is necessary to identify self-
destructive nature of patients maladaptive behaviour and to confront the patient with the fact
that self-destructive behaviour is their way of dealing with intense and intolerable affects.
According to Kerneberg (Waldinger & Gunderson, 1989), it is necessary to interpret negative
transference and maladaptive defences and to clarify contradictory ego states early in
treatment. Clarifying misunderstanding of the therapists interpretation, usually evolved by
the patients projections, can help the patient to replace primitive defences by the higher-level
defences in order to strengthen their ego and diminish distortions in interpersonal
relationships. Masterson sees transference as the reflection of the patients primary
relationships (Waldinger & Gunderson, 1989, p. 14). After the acting out is controlled, the
therapists helps patient to differentiate between the current reality of therapy and transference
distortions based on real pas experiences by using interpretations. Adler (1979, in Waldinger
& Gunderson, 1989) argues that patients longing for a perfect caregiver is the thing that
holds borderline patient in therapy and that early interpretation would only disrupt the
relationship with the therapist and the patients motivation for treatment.
Transference based psychoanalytic therapies suggest facilitation of reactivating split-off
internalized object relations and idealized natures that are then observed and interpreted in
transference. The patient is instructed to carry out free associations, while the therapists
focuses on observing activation of regressive, split-off relations in the transference,
identyfing them and interpreting them. These interpretations are based on the assumption that
each split off object relation is a part of dyadic unit of self-representation, object-
representation and a dominant affect linking them. Activation of these dyadic relationships
forms the patients perception of the therapist, who might be perceived as object-
representation in one point, while the patient identifies with primitive self-object or vice versa
in another point of therapy session. The final goal of the therapy is to associate positive and
negative transferences, integrate mutually split off idealized and persecutory segments with
the corresponding resolution of identity diffusion (Williams, 2011).
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Borderline personality disorder across cultures

Mental disorders express themselves with different symptoms in each culture. Some
disorders are seen only in specific social settings. Personality disorders are particularly
socially sensitive because they refer to behaviours and feelings that are learned in certain
culture setting.
Moriya et al. (1993) conducted a clinical study of the borderline personality disorder in
Asia involving 85 female outpatients from Japan, 32 of them diagnosed with borderline
personality disorder. The results showed that there is a psychopathological entity equivalent
to borderline personality disorder from USA in Asia, or at least in Japan. Japanese patients
scored approximately the same on anger and self-mutilating behaviour as American patients.
They scored less on substance abuse and drug induced psychotic experiences than
Americans. Japanese borderline patients showed tendency toward stormy or masochistic
relationships, and that few of them were independent (Moriya et al., 1993). Moriya argues
that it is due to the fact that most of the patients in Japan live with their parents and continue
to have such relationships with them, while American patients of that age live away from
their parents.
Bateman (1989) conducted a preliminary study of the borderline patients in Britain in
order to determine whether British patients fit into American diagnosis criteria presented in
DSM classifications. The results of the study showed that patients diagnosed with American
criteria have particular symptom profile which is not classified easily in any specific
diagnostic category used in Britain (Bateman, 1989).
When conducting cross-cultural studies on psychopathological disorders, it is always a
question whether diagnostic criteria suits the characteristics of the culture involved and their
terms of normality and sanity. Instruments used in the research represent another threat to
validity of the results of the study and their implications.
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Conclusion
Borderline personality disorder concept still needs to be investigated in order to provide
complete image of this disorder, the criteria for diagnosing it and differentiate it from other
psychological disorders in childhood. Demographic factors such as gender and age should be
further explored in context of borderline personality disorders in order to determine its
prevalence and critical age for developing the disorder.
Many factors influence developing personality disorders, among which are genes and
biological vulnerability, childhood trauma or disturbed psychological development, parental
figures and social factors including persons environment and cultural influences. All these
factors must be taken into account when discussing borderline personality. If genetic
material, diathesis and biological vulnerability cannot be changed, childs development,
family relationships and environment are the factors that could be influenced on by each
individual and the whole society in order to create a healthy context for growing up and
achieving personal well-being.
Social support system has to be provided for individuals suffering from this disorder and
their environment in order to be able to handle the distress and behavioural changes the
patient experiences. Information about the borderline personality disorder need to be
available, so that individuals experiencing emotional disturbances could identify the nature of
their disturbances and seek appropriate help. Parents need to be educated in area of child
psychological functioning in order to prevent or recognize symptoms of any kind of
disturbances and start with treatment on time.
Psychotherapy for patients with personality disorders still represents a challenge.
Identifying the best approach for each individual and developing a trusting relationship is
difficult, especially if it is a patient with borderline personality disorder. Trust issues,
idealization and deep disappointments, mood changes and behavioural inconsistency can
pose great obstacle for progress in therapy. The therapist has to be cautious in approaching
them and uncovering the potential trauma they experienced so they do not disrupt patients
involvement in therapeutic process.
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And finally, cultural context of the borderline personality disorder needs to be studied in
different cultures, in order to establish the impact of culture on development of personality
disorders. There are few studies comparing borderline symptoms and phenomenology in
Eastern and Western societies. Common diagnosis criteria and instruments need to be
established, so the findings regarding etiological, phenomenological and treatment issues
could be applied in different societies.

















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