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2000, Number 1

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Salud Mental 2000; 23 (1)

¿Quién es el paciente limítrofe?

Gómez CC

Language: Spanish
References: 49
Page: 30-38
PDF size: 145.49 Kb.


ABSTRACT

When the borderline concept is discussed in different contexts (psychiatry, psychology or psychotherapy) people frequently think they are talking about the same patient. However, different definitions arise upon reviewing this concept.
Does it refer to a specific personality disorder? To a clinical syndrome? To a functioning level between neurosis and psicosis? Is it a subtype of an affective, schizophrenic or epileptic disorder?
For the most part, the confusion comes from two different approaches striving to define the concept: the descriptive approach which emphasizes the diagnostic symptomatology vs. the psychodynamic approach that points out structural, dynamic and development considerations as diagnosis criteria. These two approaches, even though separated, are not totally unrelated. They reamin independent because their observations stem from different emphasis, contexts and methodology. Within different methods and theoretical frames, their conclusions cannot be compared although they theoretically might complement each other. The description-oriented approach representad by the DSM-IV views borderline as one of a number of distinct personality disorders, and attemps to differentiate this category from the other personality disorders. Kernberg's psychodynamic approach, in turn, considers borderline as a psychic level of functioning or a stable ego organization -somewhere in between the neurotic and the psychotic- that might giv e room to various types of personality. (Within this frame, we could talk about a narcissistic personality with a borderline level of functioning). The value of the descriptiva approach lies on the diagnosis accuracy. It is difficult, however, for such an approach to conceptualize a patient presenting strong contradictions as regards internal and external functioning. Those who support the psychodynamic diagnosis argue that, in order to fully understand the superficial adaptation of a patient concealing an internar chaos, the structural principles underlying such a complex personality should be also understood.
This review intends to clarify the difieren ways in which the borderline concept can be understood and approached nowadays: as part of the schizophrenic spectrum or the affective disorders; as a psychic level of functioning between neurosis and psychosis; as a clinical syndrome; and as a specific personality disorder.
The reviewed literature supports the concept of a borderline disorder of personality as a valid diagnostic entity, but it also seems to place the concept of borderline on a rather heterogeneous group of patients, with a high rate of comorbidity.
Within the descriptiva approach, some authors offer to redefine the concept as a real personality disorder, changing its name for greater accuracy. Other authors even suggest eliminating this term from the descriptiva nosology.
As to the psychoanalytic approach, important theorists do not talk about a specific personality disorder but of a psychopathologically stable functioning level, while others view it as a spectrum of disorders where pathology greatly varies. We thus find that when referring specifically to the DSM-IV, we are not necessarily dealing with the Gunderson, Kernberg, Akiskal or Chessick patients. There are differences that may have implications on the way this patient is approached and treated today.
Even though for some professionals the borderline entity keeps on being a vague and confusing concept, for others it is a useful way of gathering a group of difficult patients who deserve being identified for a special attention.
The present paper also includes a summary of the phenomenological and psychodynamic aspects of the borderline patient. Both approaches might complement each other in an effort to better understand such a complex personality.


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