LETTERS TO THE EDITOR The Borderline Debate Continued To the Editor: The arguments put forward by Dr. Shapiro do not, in my opinion, invalidate the reasons given by Dr. Kernberg in favor of “borderlines” before the age of 12. All they do is underline a fact we could all agree on, i.e., that we need more precise diagnostic criteria and more knowledge about long-term developments. I am one of the numerous clinicians who, as pointed out by Petti and Vela (1990), have been led for a long time now to diagnose young children as suffering from borderline and personality disorders. The terms of the diagnosis may differ from one case to another, but they are always equivalent, and I would like to add a few arguments to those already put forward by Dr. Kernberg. Classically speaking, in French psychiatric literature, the notions of ‘pre-psychosis” (Diatkine, 1969) and “evolutive disharmony” (Mis&, 1975) were developed to describe frequent clinical pictures that didn’t fill the usual criteria of neurosis or psychosis as given, for example, in the ICD-9. For some time, it was thought that these early pictures could be the antecedents of adult psychotic disorders-whence the term “pre-psychosis”-but it became evident that this was not the case and that they tended to evolve toward adult personality disorders. This led to a change in terminology that can be found in the “French classification of mental disorders in the child and in the adolescent” (MisBs et al., 1988); this classification is compatible with the projected 10th revision of the international classification of diseases (ICD- 10). In this classification, we find a category of disorders on Axis I entitled “Pathology of the Personality (excluding neurosis and psychosis). ” It includes several subcategories, one of which is the equivalent of borderline. In Switzerland, we took part in the development of this classification. In a study done in the Child PsychiaCry Service in Geneva (Manzano, l990), we found that this diagnosis was made in more than 30% of all new consultations in children under 12 during the period studied. The same proportion was found in studies carried out simultaneously in psychiatry services in other countries (Quemade and Valla, 1989, Pers. Commun.). Like myself, most clinicians are satisfied with the general category of “personality disorders” but are more reticent as to the relevance and the precision of the different subcategories and about the problem of taking the degree of severity of the disorder into consideration. Personally, I find that in a certain number of cases, the criteria used for adult personality disorders in the DSM-III-R may be used as subcategories with few differences. There are some categories of pathological personalities, in particular, that seem to constitute welldefined entities, such as “schizoid personalities” corresponding to the “schizotypal personality” (Petti and Vela, 1990), the “as i f ’ or “falseself” personality, the paranoid personality (related to the sensitive personalities of Kretchmer), and obsessional personalities. As to “depressive personalities,” it would seem important to distinguish them with greater precision from mood disorders in children. As Dr. Kernberg mentions, we are starting to get fairly reliable information on the origin and development of personality disorders and borderlines in children. Thus, in a longitudinal study we did, it became apparent that a certain number of personality disorders in 10to 12-year-olds were, in fact, the evolution of pervasive development disorders, and that, in a follow-back research, it was found that adults suffering from mood disorders had been diagnosed in childhood as suffering from personality disorders. I would therefore like to conclude by saying that, in my opinion, the question is no longer whether borderline and other personality

J . Am. Acad. Child Adolesc. Psychiatry, 30:2,March 1991

disorders exist before the age of 12, since there is already a rich data base that shows that they do (Petti and Vela, 1990); it would seem more important to develop more precise diagnostic criteria to further delineate subtypes and to undertake multisite collaborative studies in order to establish predictive validity. In view of the number of cases involved and the therapeutical repercussions, this is, for me, one of the main challenges of child psychiatry today. P.D. J. Manzano, M.D. University of Geneva, Switzerland REFERENCES

Diatkine, R. (1969), L’enfant prtpsychotique. La Psychiatrie de I‘Enfanf, XII:413-446. Manzano, J . (1990), Essai de la classification fraqaise des troubles mentaux de l’enfant et de l’adolescent B Gen2ve: ttude comparative. Neuropsychiatrie de I’Enfance et de l’Adolescence, 38: 10-1 1,565568. Misks, R. (1975), L’enfant deficient mental. In: Le Fil Rouge. Paris: Presses Universitaires de France. -Fortineau, J., Jeammet, Ph. et al. (1988), Classification franGaise des troubles mentaux de I’enfant et de l’adolescent, Psychiatrie de I‘Enfant, XXXI:67-134. Petti, T. A. & Vela, R. M. (1990), Borderline disorders of childhood: an overview. J . Am. Acad. Child Adolesc. Psychiatry, 29:327-337. Drs. Petri and Vela reply:

We wish to thank Dr. Manzano for his letter that further emphasizes the thrust of our overview: children who have been labelled as “borderline” can generally be classified into at least two major groups: (1) a borderline spectrum in which emotional instability is the prominent feature; and (2) a schizotypal spectrum with emotional detachment and social isolation as the characteristic feature. We must develop more precise measures and studies that build upon an already substantial base of clinical insight in order to further delineate subtypes of each group and allow for a differentiation between the groups of “borderline” children and differentiation from other diagnostic categories. Such advances would help minimize misdiagnosis. The two examples detailed in Dr. Manzano’s letter of affective disordered adults evolving from personality disordered children and pervasive developmental disordered children evolving into personality disordered adults should make us mindful of comorbid diagnostic categories and cautious about taking too simplistic an approach to classification. The key will be to focus on the patient, not the label, and on the clinical picture, not the exhibiting symptom. Gualtieri and associates (1983) have made the latter point, which must be considered when responding to a 30% incidence of “pathology of the personality” detailed in the letter. Furthermore, we should not allow ourselves to be drawn into the complex and largely irrelevant (to this discussion) battle concerning the scientific validity of personality disorders in children. We should also avoid the “balkanization” (Kendler, 1990) of the nosology for borderline children. Our review characterizes the evidence for the external validation of the borderline categories and cautions against both overgeneralization from the data and premature closure of our nosologic options for the involved children and their families. Vela (1989) has expanded on the issues related to validity for the “classic borderline” disorder of children. Andrulonis (1990) has provided additional data about borderline personality disorder (BPD) children. From a controlled study of children strictly diagnosed as BPD, he reports significant differences com-


The borderline debate continued.

LETTERS TO THE EDITOR The Borderline Debate Continued To the Editor: The arguments put forward by Dr. Shapiro do not, in my opinion, invalidate the re...
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