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Frijling-Schreuder, E.C. (1969). Borderline States in Children. Psychoanal. St. Child, 24:307-327.

(1969). Psychoanalytic Study of the Child, 24:307-327

Clinical Contributions

Borderline States in Children

E. C.M. Frijling-Schreuder, M.D.

SUMMARY

I would like to end with the proposal that we try to limit the diagnosis borderline state to the kind of case I have described. Freud's statement that the oedipus complex is the kernel of neurosis can also be used in differentiating between neurosis and borderline state. Hysterical acting-out personalities or disabling obsessive character formations, regardless of how severe, should be grouped under hysteria or the obsessional neurosis.

Both psychosis and borderline states can be seen as arrests of development in the symbiotic phase. However, this statement is misleading unless it takes the great complexity of mental development into account and unless the diagnosis is based on an assessment of the total personality development. We should be very careful to avoid oversimplifications, and I would like to stress again that especially the differentiation between borderline states and psychosis may be extremely difficult. I have tried to plead for basing the differential diagnosis on data from all levels of the personality.

As I see it, both childhood psychosis and childhood borderline states are arrests in the symbiotic stage of development. However, within this stage there are very great differences of development, and these differences may be responsible for the fact that the outcome in one case will be an autistic psychosis; in another, a symbiotic psychosis with more or less autistic traits; and in the third case, a borderline state showing some secondary process thinking and some mastery of impulses by means of inner speech. If we compare the reality testing of a four-month-old, a one-year-old, and a two-and-a-half-year-old normal child, who all may be in the separation-individuation phase, it is clear that the age at which the arrest occurs will determine the differences in the subsequent pathological picture. This factor is also responsible for another difference in the clinical picture; namely, the borderline case has recourse to the whole scale of defense mechanisms. He may use them in a chaotic, disorderly way, but he is not confined, as the psychotic is, to exclusive reliance on projection and primitive forms of identification.

In the borderline state there is some differentiation between ego and id. For this reason we find intersystemic conflicts. Conflicts between masculinity-femininity, active-passive, libidinal-aggressive tendencies lead, in the psychotic child, either to delusions or to complete confusion. In the borderline case, however, they may be perceived as intersystemic conflicts and give rise to a confusing mixture of phobic and obsessive and conversion symptoms. The more structured ego is more aware of the threat to its integrity, and this gives rise to the pananxiety of the borderline states. The primitive superego structure is very dependent on outer objects. The object relationships are colored by strong dependency needs which themselves hamper the establishment of genuine contact. The disturbed contact, together with the strong dependency needs, leads to rigid conformity. In a good environment this conformity may help in developing ego skills. Integration is very unstable and there are sudden and severe regressions, but there is also a tendency to reintegration. Every step in development leads to anxiety and may initiate regression, but after such a regression the reintegration may really occur at a higher level.

As a last point I would like to stress that this description is an oversimplification of the real picture. I could have stressed the preoedipal traits in neurosis, the onset of oedipal development in a borderline case. I could even have stressed the mature character traits that we find in adult borderline patients whom we have known from childhood. Ultimately, all psychiatric classification may well differ from one country to another, from one clinic to another. I hope that I have illustrated how important it is to use all our analytic knowledge even in the diagnosis of very disturbed children. Only by assessing the total personality and the deviations of development in every area of the personality can we formulate rational treatment programs.

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