An illustration borderline personality pathology

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Some clinicians may doubt that a finite set of 200 statements can capture the richness and complexity of clinical case description. However, SWAP statements can be combined in virtually infinite patterns to express subtle clinical concepts. The mathematically inclined reader might note that there are 200 factorial possible orderings of the SWAP statements, which is an inexpressibly large number. The musically inclined reader might note that all of Western music can be notated using combinations of only twelve tones.

Many clinical theorists consider splitting, projective identification, and identity disturbance to be hallmarks of borderline personality pathology (e.g., Clarkin, Yeomans, & Kernberg, 2006; Kernberg, 1975, 1984; Linehan, 1993; McWilliams, 1994). Consider, for example, the items reproduced below from the original SWAP-200 item set. The three items, taken in combination, convey something of the defensive splitting seen in patients with borderline personality pathology:

SWAP Item # SWAP Item Text

162 Expresses contradictory feelings or beliefs without being disturbed by the inconsistency; has little need to reconcile or resolve contradictory ideas.

45 Tends to idealize certain others in unrealistic ways; sees them as "all good," to the exclusion of commonplace human defects.

79 Tends to see certain others as "all bad," and loses the capacity to perceive any positive qualities the person may have.

The following items, from the SWAP-II, capture some additional meanings of the concept splitting.

9 When upset, has trouble perceiving both positive and negative qualities in the same person at the same time (e.g., may see others in black or white terms, shift suddenly from seeing someone as caring to seeing him/her as malevolent and intentionally hurtful, etc.).

18 Tends to stir up conflict or animosity between other people (e.g., may portray a situation differently to different people, leading them to form contradictory views or work at cross purposes).

The next group of items, taken in combination, captures at least one meaning of the term projective identification:

116 Tends to see own unacceptable feelings or impulses in other people instead of in him/herself.

76 Manages to elicit in others feelings similar to those s/he is experiencing

(e.g., when angry, acts in such a way as to provoke anger in others; when anxious, acts in such a way as to induce anxiety in others).

154 Tends to draw others into scenarios, or "pull" them into roles, that feel alien or unfamiliar (e.g., being uncharacteristically insensitive or cruel, feeling like the only person in the world who can help, etc.).

The concept identity disturbance (or identity diffusion) subsumes a wide range of phenomena (Wilkinson-Ryan & Westen, 2000). When the same term has been used in the literature in different ways, or used differently by different theorists, we wrote multiple SWAP items to cover the multiple meanings. The following SWAP-II items illustrate some of the manifestations and facets of identity disturbance:

15 Lacks a stable sense of who s/he is (e.g., attitudes, values, goals, and feelings about self seem unstable or ever-changing).

151 Appears to experience the past as a series of disjointed or disconnected events;

has difficulty giving a coherent account of his/her life story.

90 Is prone to painful feelings of emptiness (e.g., may feel lost, bereft, abjectly alone even in the presence of others, etc.).

172 Seems unable to settle into, or sustain commitment to, identity-defining life roles

SWAP Item # SWAP Item Text

150 Tends to identify with admired others to an exaggerated degree, taking on their attitudes, mannerisms, etc. (e.g., may be drawn into the "orbit" of a strong or charismatic personality).

87 Sense of identity revolves around a "cause," movement, or label (e.g., adult child of alcoholic, adult survivor, environmentalist, born-again Christian, etc.); may be drawn to extreme or all-encompassing belief systems.

38 Tends to feel s/he is not his/her true self with others; may feel false or fraudulent.

102 Has a deep sense of inner badness; sees self as damaged, evil, or rotten to the core (whether consciously or unconsciously).

The next group of items helps flesh out a picture of a certain kind of borderline patient, addressing issues of affect regulation, interpersonal relations, cognition, and so on:

191 Emotions tend to change rapidly and unpredictably.

12 Emotions tend to spiral out of control, leading to extremes of anxiety, sadness, rage, etc.

185 Is prone to intense anger, out of proportion to the situation at hand (e.g., has rage episodes).

157 Tends to become irrational when strong emotions are stirred up; may show a significant decline from customary level of functioning.

117 Is unable to soothe or comfort him/herself without the help of another person

(i.e., has difficulty regulating own emotions).

98 Tends to fear s/he will be rejected or abandoned.

11 Tends to become attached quickly or intensely; develops feelings, expectations, etc. that are not warranted by the history or context of the relationship.

167 Is simultaneously needy of, and rejecting toward, others (e.g., craves intimacy and caring, but tends to reject it when offered).

153 Relationships tend to be unstable, chaotic, and rapidly changing.

52 Has little empathy; seems unable or unwilling to understand or respond to others'

needs or feelings.

176 Tends to confuse own thoughts, feelings, or personality traits with those of others

(e.g., may use the same words to describe him/herself and another person, believe the two share identical thoughts and feelings, etc.).

41 Appears unable to describe important others in a way that conveys a sense of who they are as people; descriptions of others come across as two-dimensional and lacking in richness.

29 Has difficulty making sense of other people's behavior; tends to misunderstand, misinterpret, or be confused by others' actions and reactions.

The last group of items, below, includes descriptors that might apply to a more disturbed type of borderline patient, perhaps one likely to be seen in an inpatient setting (Gunderson, 2001):

SWAP Item # SWAP Item Text

134 Tends to act impulsively (e.g., acts without forethought or concern for consequences).

142 Tends to make repeated suicidal threats or gestures, either as a "cry for help" or as an effort to manipulate others.

109 Tends to engage in self-mutilating behavior (e.g., self-cutting, self-burning, etc.).

188 Work-life and/or living arrangements tend to be chaotic or unstable (e.g., job or housing situation seems always temporary, transitional, or ill-defined).

44 When distressed, perception of reality can become grossly impaired

(e.g., thinking may seem delusional).

The items reproduced here are illustrative only and are not intended to describe "the" borderline patient or any particular borderline patient. They are intended only to illustrate that it is possible to describe clinically sophisticated constructs without succumbing to either reductionism or jargon. Further, such descriptions are empirically testable.

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