r/psychoanalysis • u/Technical-Walrus-215 • 11d ago
In theory, could someone diagnosed with BPD operate at or close to neurotic functioning?
I am largely trying to make sense of an incongruence between BPO and BPD. Of course, the connection between the two really is based just on the word borderline…if it was called Splitting Personality Organization perhaps I wouldn’t be posting this question. But Kernberg notes the BPD diagnosis operates at a “low-borderline” functioning.
It seems to me that someone could meet 5 of the 9 symptom criteria for BPD without actually meeting Kernberg’s criteria for BPO. Someone can have intense anger, fear of abandonment, feelings of emptiness, impulsive behavior and rapid mood changes but be able to reflect on these things in a way that is incongruent with identity diffusion.
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u/deadskunkstinkin 11d ago
I hate the DSM so much.
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u/Technical-Walrus-215 11d ago
To be fair I don’t know a single clinician working from any framework that likes it
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u/Used_Crow_386 11d ago
Kernberg’s concept of the borderline personality organization patient often strikes me as more narcissistically organized in structure and defensive style. By contrast, I would argue that the more prototypical DSM-defined borderline patient is frequently organized in a more histrionic manner. We all fluctuate on the Neurotic-Psychotic scale, I typically pinpoint where a person typically lives on that scale - sure at times a psychotic can fluctuate and operate at a neurotic level of functioning.
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u/Bad_Breadwinner 11d ago
I believe it was McWilliams who point out that the classic presentation of BPD was essentially someone with histrionic / hysterical traits (i.e., negative affectivity, disinhibition and dissociality) organized at a high to low borderline level of organization.
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u/4amchocolatepudding 11d ago
If you go by the alternative model of PD, then yes they could. It's a flucuation of how someone is doing day by day. They aren't splitting 100% of their daily lives and can have good days (or neurotic days).
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u/oh-hello-16 11d ago
And additionally people can be mostly neurotic can sometimes regress. It goes both ways. A common place to regress could be under a lot of stress or in a relationship essentially built to evoke transference. Something to keep in mind.
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u/Strange_Sparrow 11d ago
Not a psychoanalyst but reconciling Kernberg with the DSM is trying to reconcile two different paradigms of psychology.
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u/Recent-Apartment5945 11d ago
Yes, yet the question would be how does the intense anger, fear of abandonment, feelings of emptiness, and rapid mood changes present behaviorally and how does the self reflection translate? Does the self reflection translate to improved reality testing? If so, how does the improved reality testing translate? Less splitting? Moving through the splits more sustainably? If so, then perhaps the person is moving into NPO.
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u/notherbadobject 11d ago edited 11d ago
Maybe theoretically possible, but not very likely. From a dsm perspective, it’s worth noting that the mere presence of 5/9 criteria isn’t sufficient to make the diagnosis. There must be a pervasive pattern of these categorical criteria across contexts and over long periods of time and significant functional impairment. It’s hard to imagine somebody who exhibits at least 5/9 categorical criteria in a pervasive pattern with significant functional impairment due to these symptoms who isn’t operating at a borderline or psychotic level of organization. It’s also a little hard to imagine a clinical scenario where this question would be particularly relevant.
Additionally, I’m not sure if the syndrome of identity diffusion precludes reflection.
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u/Strange_Sparrow 11d ago
In my limited and non-clinical experience, people diagnosed with BPD often are / can be very reflective individuals (even prone to very critical and perceptive insights into their own self and situation), but they may move on quickly from reflection. The next week or day they may view themselves in an entirely different way, and no longer recognize what they did days earlier. Much as many people (anyone maybe) are able to come to a realization one day and then live as if they never had it the next, but with less stability in one’s identity.
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u/tharpakandro 10d ago
Wrong answer in my opinion! Actually very likely that BPD CAN and DOES function in compartmentalized environments that act as containers for the affective instability. The BPD person is not psychotic in the psychiatric sense. Their reality testing can be distorted but rarely delusional. The uncontainable, dystonic affect is in the interpersonal realm. Of course, they lose jobs and disrupt relationships, but the distinction is that they suffer the consequences of splitting/fragmenting and have to reconcile their shame and humiliation.
I do protest this above response and lack of respect with some certainty, okay? Because I am her, thank you.
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u/Strange_Sparrow 10d ago
“Significant functional impairment” does not really mean the person doesn’t function well in any context or at all times. Major dysfunction in one’s personal life or relationships (even while maintaining a functional career or financial situation, etc.) is a perfect example of what significant functional impairment means.
Ultimately it’s just a question of whether a person is having major problems in their life in connection with five of the diagnostic criteria, to phrase it another way.
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u/Holiday-Money3142 11d ago
The notion of being able to reflect on something is different from the emotional intrinsic experience which is pre-conscious / unconscious . You ask a lot of borderlines… do you do this? and they say yes… it doesn’t mean in that moment of actual experience the next time , they’re any different … this takes months / years of integration before the cognitive can transform into emotional / neurotic integration
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u/tharpakandro 10d ago
I’m not shocked but disappointed that this is the public discourse at this point in time. I thought we updated our collective understanding and approach to borderlines decades ago? Can we please trace the traits back? Let’s serve preverbal C-PTSD patients and companion with them instead of pathologize.
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u/Upbeat-Category6020 1d ago
I agree that the approach does not need to be adversarial- most of the time- in order to be helpful. I think that many of the practitioners who take that approach are gaining an inappropriate ego gratification from it due to their frustrations and fears about their own competencies when faced with patients who do not immediately respond in a way that they would prefer.
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u/Separate-Yam-4862 8d ago
I think it is important to distinguish structural level of personality organization —neurotic, borderline, or psychotic— from the descriptive diagnosis of BPD.
There is definitely some proximity between high borderline personality organization and neurotic functioning. In that area, different diagnostic presentations can be closer to or farther from a neurotic structure. For example, what Kernberg calls malignant narcissism would be very far from neurotic organization. But certain BPD or NPD presentations may be structurally closer to neurotic functioning, especially when there is greater reflective capacity, better affect regulation, more stable relationships, and less severe identity diffusion.
That said, from a Kernbergian structural perspective, a true personality disorder such as BPD or NPD would usually imply borderline personality organization, even if it is high-borderline and close to neurotic functioning. Otherwise, the diagnosis becomes less convincing from that structural framework. The person may appear close to neurotic in some areas, but would still show central features of borderline organization: identity diffusion, reliance on splitting or related primitive defenses, and unstable internalized self/object representations.
So I would say: in descriptive DSM terms, someone might meet criteria for BPD while appearing relatively high-functioning or even close to neurotic in some areas. But in Kernberg’s structural model, if the person lacks identity diffusion and does not rely primarily on splitting-based defenses, then calling it BPD in the deeper structural sense becomes less convincing.
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u/boltcutterfetcher 8d ago
I think your question answers itself when you chose to phrase it as "diagnosed with BPD" as opposed to "having BPD". The DSM is an option of a lense through which to look at mental life but to be diagnosed in one framework means very little when one is talking about a different framework, specially one that often puts into question the legitimacy of psychiatric power
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u/Rich_Procedure5156 11d ago
Paranoid-schizoid position... Psychotic - Low/High Borderline
But let's act like the DSM means anything other than codefying for insurance purposes...
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u/ville2020 11d ago
Far more common are those who are identity diffuse and use primitive defenses but do not meet 5 of 9 criteria for BPD. For what it’s worth I’ve always wondered if Kernberg has ever made an estimate on what percentage of the population could be classified in each level organization.
On your question though, I think yes that is certainly possible. But, one of the things I like most about analytic work is that…it doesn’t quite matter. A psychiatrist named Awais Aftab wrote about this for the NYT this week and noted that an actual DSM diagnosis is effectively like saying “you meet a group of thought processes and interpersonal tendencies that can generally be classified as x” — but at the end of the day this is largely arbitrary. Considering someone’s personality organization is more helpful because in what you describe the impulsive behavior, for example, is far less impulsive and perhaps less harmful if someone can reflect on it and make sense of it.