..classified as a major personality disorder involving dramatic, emotional, or erratic behavior; intense, unstable moods and relationships; chronic anger; and substance abuse." (Boucher, 1999, p. 33) There are a number of criteria which, in line with DSM-IV, are used to identify and characterize this disorder. The first of these criteria refers to "...unstable and intense interpersonal relationships, with marked shifts in attitudes toward others (from idealization to devaluation or from clinging dependency to isolation and avoidance), and prominent patterns of manipulation of others.."(Boucher, 1999, p. 33)

Perception also plays an important role in the identification and understanding of the BDP patient. This refers particularly to social perception. Benjamin and Wonderlich (1994) recognized that BDP patients showed differences in social perception when compared to bipolar and unipolar subjects. In relation to this they found that "...BPDs view relationships with their mothers, hospital staff, and other patients with more hostility than mood disordered patients. BPDs see themselves as attacked by other patients and as part of hostile and noncohesive families. "(Boucher, 1999, p. 33)

Another aspect that identifies the BDP sufferer is "... intense clinging dependency and manipulation..." (Boucher, 1999, p. 33) This is a central characteristic of the BDP patient in terms of social interaction and is an aspect which also makes the treatment of this patient all the more difficult.

Therefore a further cardinal criterion of these patients is that they show major social dysfrucntionality. As Boucher in his study (1999) states,

Hostility enters on the heels of denial of dependency; as part of vehement denial, BPDs devalue the strengths and personal significance of others. Often, this takes the form of extreme anger when others set limits for relationships, or when separations are about to occur. Social perception is pervasively dysfunctional. (Boucher, 1999, p. 33)

Understanding BPD is a precarious and difficult issue in many instances. As stated, one of the issues surrounding BDP is the difficulty in diagnosis and assessment due to the interrelationships and similarities to other disorders and areas of mental concern. This is evidenced by the fact that while BDP is often diagnosed in children and adolescents, one has to must make allowance for other issues including eating disorders, substance abuse, and mood disorders that may be age specific.

BPD is often diagnosed in children and adolescents. However, considerable caution should be used when doing so, as some of the symptoms of BPD (e.g., identity disturbance, hostility, and unstable relationships) could be confused with a normal adolescent rebellion or identity crisis. (Coker & Widiger, 2005, p. 213)

1.2. Diagnostic and Statistical Manual of Mental Disorders (DSM)

As discussed above, the earlier history of the definition, identification and classification of Borderline Personality Disorder was unclear and uncertain - especially with regard to its differentiation from other neurotic conditions.

Due to this fact the Diagnostic and Statistical Manual of Mental Disorders, Second Edition, (DSM-II) contained very little that adequately described or identified the Borderline personality. However, inline with the growing definitions and awareness of BPD as a unique condition with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, (DSM-III), BPD became a diagnostically based on a systematic description of observable clinical characteristics. "This description was carried over to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, (DSM-III-R) in 1987 and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in 1994. "(Excerpt from Personality Disorder: Borderline)

According to the DSM-IV (1994) BPD is a ":...pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of nine criteria." (Boucher, 1999, p. 33) Some of these criteria have been referred to in the above section. The following is a listing of the nine criteria.

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called "splitting."

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in (5).

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty...

Transient, stress-related paranoid ideation or severe dissociative symptoms.
What is Borderline Personality Disorder?)

The DIB-R is the considered as the most influential method of diagnosing BPD. This had led researcher to identify four central behavior patterns that are particular to BDP. These are "... abandonment, engulfment, annihilation fears; demandingness and entitlement; treatment regressions; and ability to arouse inappropriately close or hostile treatment relationships." (Borderline Personality Disorder)

1.3 Etiology

In terms of prevalence, indication it is estimated that approximately 1% to 2% of the general population would meet the DSM -- IV criteria for BPD (Coker & Widiger, 2005, p. 213)

Furthermore "BPD is the most prevalent personality disorder within most clinical settings (although perhaps not the most prevalent in community settings...)." (Coker & Widiger, 2005, p. 213)

Coker and Winder state in their study Personality Disorders, that about 15% of all inpatients or 51% of inpatients with a personality disorder and 8% of all outpatients or 27% of outpatients with a personality disorder, will meet criteria for borderline personality disorder. Further statistics show that in terms of gender demographics about 75% of persons with BPD will be female (Coker & Widiger, 2005)

In terms of figures relating to mortality and morbidity it was found that the number of premature deaths in patients with BPD may be due to an increased risk of suicide. This is supported by the fact that "... Approximately 70-75% of patients with BPD have a history of at least one deliberate act of self-harm." (Excerpt from Personality Disorder: Borderline)

An important aspect in understanding Borderline Personality Disorder is the significance of comorbid conditions. These can include dysthymia, major depression, psychoactive substance abuse, and psychotic disorders. (Excerpt from Personality Disorder: Borderline) In a 1999 study of 409 patients it was found that patients with BPD were twice as likely to receive a diagnosis of 3 or more current axis-I disorders and that they were nearly 4 times as likely to have a diagnosis of 4 or more axis-I disorders. These included mood disorders, anxiety, substance abuse, eating disorders, and somatoform disorders.

Excerpt from Personality Disorder: Borderline)

An interesting note in terms of the demographics of BPD is that the initial diagnosis of the disorder is rarely found in patients who are older than forty years of age.

The general symptomatic indicators are that those with BPD can be identified by factors such as emotional instability and impulsive behavior. BPD patients also show signs of hostility when young and abnormal affectivity and impulsivity during adolescence. Gunderson (2001) states that,

As adults, persons with BPD may be repeatedly hospitalized, because of their affect and impulse dyscontrol, psychotic-like and dissociative symptomatology, and risk of suicide and suicide attempts (Gunderson, 2001; Zanarini et al., 1998a). These individuals are at a high risk for developing depressive, substance-related, bulimic, and posttraumatic stress disorders" (Coker & Widiger, 2005, p. 213) RR

One of the defining aspects of BPD is extremely high neuroticism.

In particular, these individuals are at the very highest range of anxiousness, angry hostility, depressiveness, impulsiveness, and vulnerability. Borderline clients will also likely be low in the agreeableness facets of trust and compliance and low on the conscientiousness facet of competence. (Coker & Widiger, 2005, p. 213)

The reasons for this condition are related to many aspect and theories, ranging from biological causative factors to social and environmental factors. The various pathogenic mechanisms are dealt with in numerous, and often very different theoretical stances. Many of the theories as to the origins of BPD are related to social and environmental factors such as abandonment, separation, and/or exploitative abuse. This is one of the reason why "frantic efforts to avoid abandonment" is the first item in the DSM -- IV-TR diagnostic criterion set (Coker & Widiger, 2005, p. 212)

Another theoretical causative factor that is referred to is disturbed, abusive or broken relationships. This often results in "... The development of malevolent perceptions and expectations of other." (Coker & Widiger, 2005, p. 212)

In turn, these perceptions of others, coupled with the inability to control affect, may "...contribute to the perpetuation of intense, hostile, and unstable relationships. Coker & Widiger, 2005, p. 212)

DBT

On of the most persuasive theories of the causative foundations of Borderline Personality Disorder is provided by Linehan, who has developed a comprehensive sociobiological theory which " appears to be borne out by the successes found in controlled studies of her Dialectical Behavioral Therapy." (Borderline Personality Disorder)

While this theory will be dealt with in greater detail in the second section…