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Mental Disorders

by John G. Gunderson
American Psychiatric Press, 2001
Review by Danny Sullivan, MBBS on Oct 15th 2001

Borderline Personality DisorderBorderline Personality Disorder (BPD) is a diagnosis which carries pejorative connotations, and which proves difficult to deal with clinically. Furthermore, it is a diagnosis which proves controversial in psychiatric nosology: it is gender-laden, etiologically contentious, and linked to therapeutically nihilistic attitudes.

Gunderson is well-credentialed to discuss the issues around BPD. In such a controversial field, some will harbor partisan opinions; others will seek to proselytize; indeed, the psychodynamics of BPD suffuse attitudes towards discussing it. Gunderson manages to rise above the trench warfare and present a work which encompasses many viewpoints, but is critical. It is fairly straightforward to determine, in his discussion, what is evidence and what is opinion. This is, therefore, a splendid manual for those who have contact with BPD.

It is pointed out from the beginning that BPD is a common diagnosis, and one which arouses strong contentions. Gunderson begins with historical discussion of BPD, from Kernberg, through Grinker and the author himself into DSM-IV. He doesn't shrink from describing the controversies and uncertainties in the diagnosis. The expansion of DSM-IV criteria is rich in simple clinical detail. The phenomenology of BPD becomes more clear, particularly given the historic and clinical confusion of BPD with other psychiatric illnesses. The author is happy to address the label of BPD for 'heartsink' patients, and succeeds well in setting up a primary contention: that the diagnosis has validity and clinical relevance.

Gunderson then rapidly sets out his premise: that BPD is treatable - but over a long period of time. This is a powerful message for those responsible for funding service development. He then continues to clarify the comorbidities of BPD. The author is staunch in resisting a monistic model, seeking rather to point out similarities in experiential and diagnostic issues which may lead to confusion in diagnosis of BPD.

The book then continues by suggesting a variety of treatment goals, and ways in which therapies may serve to benefit the BPD patient. This is a clear, explicit, and realistic way of regarding treatment trajectory in the BPD patient. There are detailed and understandable points of advice to the therapist, in responding to crises and reframing frantic pleas for help. In particular, Gunderson refers to the defence mechanism of splitting as used by BPD patients, and subverts it by suggesting his principle of split treatment, which ensures that the BPD patient can be contained by referring to an alternative 'good object'.

Further discussion focuses on the differing intensities of treatment interventions, with a frank discussion of the merits and drawbacks of hospitalisation and of medication. Unusually for discussions of interventions, the focus is as much on the effect on transference as it is on effectiveness and outcome. Medications are discussed from the viewpoint of specific behaviours to be treated, and evidence for efficacy linked to the overall effect on treatment.

In addressing psychotherapies, Gunderson divides these into cognitive-behavioural (including Dialectical Behavioural Therapy), family therapies, and interpersonal group therapies. He then addresses individual psychotherapies and discusses the various stages of therapy. The discussion is simple and easy to apply, including examples of dialogue and difficult clinical situations.

This is an impressive book. The style is thoroughly readable. Although well-referenced, it doesn't read like a literature review. This is because Gunderson is very explicit in his discussion, acknowledging controversy , putting across his opinion but not claiming it as incontrovertible. At the end of it all, the reader is left with a sense of understanding and, surprisingly, of optimism about treatment for BPD. This is a surprising consequence for a book on such a vexed topic.

© 2001 Daniel Sullivan

Danny Sullivan graduated in medicine in Australia in 1994. He has since completed a Masters Degree in Bioethics and a Masters Degree in Medical Law. He is training in psychiatry at the Maudsley Hospital and Institute of Psychiatry in London, UK, and remains an Honorary Research Associate of Monash University.

This review first appeared online on October 1, 2001.

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