Allison Riege, Mark Ruffalo, David Puder

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Borderline Personality Organization (BPO) is characterized by the use of primitive defenses (e.g., denial, splitting, projective identification) and identity diffusion. First described by Kernberg in 1968, BPO remains useful in clinical practice for conceptualizing patients without classic borderline personality disorder symptoms like cutting, self-harm, or emotional volatility. These individuals may present with borderline-level functioning (primitive defenses, identity diffusion) but in more introverted forms, such as schizoid or dependent personalities, or with more narcissistic traits. Recognizing identity diffusion allows for greater empathetic attunement and clinical efficacy in many important ways, it allows the practitioner to attune to transferences, projective identification, and garner a better conceptualization of the patient’s unique suffering.

Patients in the borderline range do not exhibit psychosis characteristic of conditions such as schizophrenia or acute mania, where reality testing is profoundly impaired and insight is lacking, making it difficult to present a “social veneer” of normalcy. At the same time they are not functioning at the healthy/neurotic level, which is characterized by the use of more mature defenses (such as sublimation, humor, reaction formation, intellectualization) and a cohesive, stable sense of self that allows for more resilience to stress and change.

Categorizing identity diffusion as primarily characteristic of BPD in diagnostic systems like the DSM-5 may have limited the attention to the prevalence and significance of identity issues across personality disorders, obscuring the understanding that the borderline-level of functioning transcends specific styles. This has fueled confusion between borderline personality organization (a structural organization) and BPD (a specific descriptive syndrome), though they are interconnected yet distinct concepts.

In this article we will first discuss the history of identity diffusion, subsequently review two articles on the topic, and finally, discuss practical, helpful approaches. 

The History Of Identity Diffusion

Early psychoanalysts like Helene Deutsch (1930s) first introduced the notion of identity diffusion through her observations of the “as if” personality. She described a superficially intact identity that lacked depth and authenticity. Deutsch noted that individuals with the “as if” personality seemingly mimicked the identities and emotional experiences of others in an effort to mask a core sense of emptiness, living “as if” they possessed genuine feelings and desires, but yet the borrowed emotional experiences were artificial. The outward presentation is a facade that conceals an internal sense of emptiness and uncertainty. As such, she observed that individuals functioning with an “as if” personality tend to have superficial relationships and struggle with intimacy (you can’t receive empathy for a facade). 

It is generally accepted that the quality of interactions with early attachment figures lays the foundation for the development of an integrated and cohesive identity. When attachment figures are nurturing and consistent, children gradually develop the ability to recognize and integrate both positive and negative aspects of themselves and others, leading to a stable sense of identity and realistic expectations. In contrast, inconsistencies or failures in early childhood relationships with caregivers can negatively affect this process. Consequently, when a child fails to integrate positive and negative aspects of self and others, it can foster a fragmented and unstable internal world alongside distorted views of others. Ultimately, the quality of these early relational experiences influences not only the child’s identity development, but also their method of experiencing and coping with emotions, defensive processes, and expectations and perceptions of relationships throughout their life. 

Based on prominent influential concepts of personality development, Akhtar (1992) developed a pantheoretical description of key characteristics that constitute a solid and stable identity as: 

  1. A sustained feeling of self-sameness displaying roughly similar character traits to varied others

  2. Temporal continuity in the self-experience

  3. Genuineness and authenticity

  4. A realistic body image

  5. A sense of inner solidity and the associated capacity for peaceful solitude

  6. Subjective clarity regarding one’s gender

  7. An inner solidarity with an ethnic group’s ideals and a well-internalized conscience 

Disturbances in these areas of functioning comprise the syndrome of identity diffusion.

Erik Erikson explored the phenomena of identity development, recognizing identity vs. role confusion as a critical stage of normal identity development occurring in adolescence. He posited that failure to resolve a cohesive sense of self that remains consistent across time and place differentiates a normal, healthy identity from a fragmented, diffused sense of self. However, it is likely that someone with identity diffusion has gaps in multiple states of Eriksonian development, such as issues with trust, lack of autonomy, and issues with initiative. 

Kernberg And Borderline Range Of Functioning

Otto Kernberg, greatly influenced by object relations theory, developed a structural framework for understanding personality organization and, in turn, a method of assessing and conceptualizing personality pathology. His model included three primary levels of personality functioning: the neurotic/healthy range, the borderline range, and the psychotic range. Assessing the level of functioning depends on several factors, including the quality of identity integration, primary defense mechanisms, reality testing, and object relations. Broadly, determining personality organization has fundamental implications for diagnosis, conceptualization, and treatment within the psychodynamic field of psychotherapy and psychiatry.

Much of Kernberg's ensuing work focused on defining key features of the borderline range of functioning. Historically, patients in this range were challenging to diagnose; they were not overtly psychotic, with reality testing largely intact, but they were vulnerable to regress to transient psychotic states under specific circumstances and stressors. They often relied on primitive defensive operations, especially splitting. Their identities had a superficial fragmented quality, characterized by unstable and contradictory states, and close relationships were often dysfunctional, unfulfilling, and challenging to maintain.

Kernberg first introduced the concept of identity diffusion as a defining feature of borderline personality organization. He discussed the predominant features of identity disturbance as: a poorly integrated sense of self and others, contradictory self-images, temporal discontinuity of the self, and chronic inner emptiness. He argued that identity diffusion arises from the persistent use of primitive defense mechanisms, such as splitting and creating fragmented internal representations.

Kernberg’s conceptualization evolved into practical tools, including the Inventory of Personality Organization (IPO), an empirically based self-report instrument measuring identity diffusion. During this period, Kernberg, alongside John Clarkin and Frank Yeomans, developed Transference-Focused Psychotherapy (TFP), a treatment modality specifically targeting identity diffusion through therapeutic exploration and integration of fragmented self-perceptions.

John Gunderson And BPD

John Gunderson was a Harvard psychiatrist who began his career studying and treating schizophrenia. In the 1970s, he became interested in the problem of “borderline” or “atypical” schizophrenia and wrote an influential paper with Margaret Singer in 1975 identifying borderline personality disorder as a distinct psychiatric illness. By the late 1970s, his work on the descriptive phenomenology of BPD led the DSM-III Task Force to include the diagnosis as a personality disorder, and BPD was subsequently recognized by Kernberg as a specific form of pathology existing at the borderline level of personality functioning.

While Gunderson’s initial formulation of BPD did not explicitly incorporate identity diffusion, by the late 1970s he recognized unstable identity as central to BPD, contributing to the inclusion of “identity disturbance” as a diagnostic criterion in DSM-III in 1980. Throughout the 1980s, he elaborated on identity disturbance, describing it as an unstable and often distorted self-image integral to BPD. In the 1990s, Gunderson linked identity diffusion to interpersonal dynamics, highlighting intolerance of aloneness and insecure attachments as foundational to identity instability.

In subsequent decades, Gunderson advocated for retaining identity disturbance in diagnostic models, proposing nuanced refinements emphasizing its relationship with chronic emptiness and interpersonal difficulties. He remained a staunch advocate for the diagnosis of BPD until his death in 2019, finding that the disorder was the most robustly validated of the DSM personality disorders (along with antisocial personality disorder) and developing a specific psychodynamically-informed treatment for BPD called good psychiatric management (GPM).

Akhtar’s Description of Identity Diffusion

Contradictory Character Traits

Individuals with identity diffusion display contradictory personality attributes, such as marked tenderness coexisting with extreme indifference, naiveté and suspiciousness, greed and self-denial, arrogance and timidity, boldness and shyness, or generosity and stinginess. These contradictions are maintained through the defense mechanism of splitting, where positive and negative aspects of the self are kept separate to avoid internal conflict. Because they cannot hold an integrated view of themselves in mind, they similarly struggle to construct cohesive understandings of others, leading to misunderstandings and a reliance on immediate behaviors as a mental model rather than deeper mental states. This is also linked to pursuing multiple completely antithetical vocational goals. 

A person with many internal contradictions will likely need someone to help them patiently untangle their lack of coherence. The therapist, in turn, will also need to be ready for moments when the patient misunderstands the therapist. With a lack of awareness of mental states, both in oneself and others, a tendency towards black and white views, and a focus on explanations tied to events rather than mental state, a clinician will need to be ready for various transferences and look for disavowed emotions. Therapeutically, if clinicians simply point out discrepancies, this will potentially be shame-inducing. Also, the patient may vacillate towards the therapist’s inherent proclivities and ideological dispositions, even without the therapist realizing what is occurring. Real emotion, often disavowed and replaced with dissociation, can come in “hot and strong” or pointed directly at the clinician. 

Temporal Discontinuity in the Self

A key marker of a stable identity is the ability to maintain consistency through shifts and over the years. For those with identity diffusion, this continuity is compromised, with memories of the past, sensations in the present, and visions of the future failing to connect into a coherent sequence. Individuals might sense themselves as childlike yet irreversibly aged. Waves of deep yearning for earlier times alternate with urgent forward planning, isolating the current moment from both history and anticipation, making every event feel strangely immediate and endowing time with a subjective, broken essence. A comprehensive life review often exposes an existence marked by disjointed episodes, akin to Pfeiffer's notion of “a life lived in pieces.” In younger people, this disrupts the capacity to envision ahead and set steady objectives; in midlife, it can create a strange detachment from one’s earlier versions. There is no rootedness in their history and difficulty in conception of future goals or desires. Common countermeasures against this unsettling rupture include assembling time-ordered photo collections, maintaining copious private journals, endlessly probing personal origins, and dwelling excessively on outside happenings, which are all efforts to anchor a fragile sense of ongoing being. Writing and getting to closer and higher degrees of accuracy on one’s narrative might be part of the healing process.  

Someone with higher reflective function will have continuity of their self-experience, where their past, present and future are meaningfully connected.  

Lack of Authenticity

Individuals with identity diffusion often present with feelings, beliefs, and actions that appear emulated or copied. They tend to mimic others’ identities rather than forging one on the solid foundation of secure early attachments and the empathetic attunement that uncovers unique giftedness. They emulate to feel loved and accepted; the more perceptive the patient, the more they pick up on subtle cues to gain attention and validation even from the therapist. Many practitioners have noted this dynamic, including Helene Deutsch’s “as-if” personality, where individuals live through borrowed roles; Winnicott’s “false self,” a compliant facade shielding vulnerability; and Karen Horney’s conception of neurotic ambition, driven by internalized “shoulds” that foster a projected false image over authentic self-expression. The patient might say something, but it may lack emotional congruence—for example, mismatched microexpressions or body language, or seeming detached from their actual enthusiasm. For these patients, their most true experience might not be their words, but rather their art, dreams, or bodily sensations. 

Feelings of Emptiness 

The profound emptiness, which can be described as “hollow” or “just a shell,” contrasts with normal loneliness. In normal loneliness there is a painful longing for a fantasized person or experience. In emptiness there is no longing, there is a lack of capacity to have a fantasy for a person or experience. The emptiness is deeply dehumanizing and frightening. In loneliness, because there is a fantasy, mourning is present for the feeling of loss. In emptiness, there may be various compulsions to fill the void, including, compulsive socializing, bulimic episodes, drinking, drugs, and self-mutilation. Without social contact there can be a feeling of hollowness, a “deadening of inner emotional experience” and an intolerance of aloneness. Others can act as a way to self-sooth. There can be a constant quest for the ideal other to be a sustaining presence. 

Gender Dysphoria

A cohesive gender identity is in harmony with sexual identification. It is important to consider changes in our understanding of gender norms and fluidity since the article’s publication date, however dysphoria can be a significant feature of identity diffusion and shouldn’t be ignored. There does appear to be a relationship between identity diffusion and gender dysphoria, but it is challenging to discuss now because of the current cultural/political climate. Ultimately it is important to look at the global picture of identity diffusion, not just a single indicator, but meaningful to consider this piece as possibly related to and significant to a broader identity diffusion. Gender is part of identity, as such, gender dysphoria may be related to diffuse sense of self. In this domain, the patient may lack solidarity around core gender identity, an awareness of belonging to one sex and not the other, and gender role.

Inordinate Ethnic and Moral Relativism

In addition to these features, Akhtar (1984) noted that disturbances of conscience and cultural belonging can assume exaggerated forms, producing what he termed “inordinate ethnic and moral relativism.” In such cases, individuals lack an inner anchor for moral judgment or group solidarity, leaving them vulnerable to adopting shifting ideological, ethical, or ethnic identifications in a manner that appears adaptive but is, in fact, another expression of fragmentation. Just as contradictory traits and temporal discontinuity destabilize the self, so too does this moral and cultural fluidity undermine the development of a consistent value system. The patient may enthusiastically endorse one political, religious, or ethnic identity, only to disavow it in favor of another when circumstances change. What appears on the surface to be tolerance or cosmopolitanism may actually reflect a fragile identity struggling to locate permanence in shifting external markers. For the clinician, this requires careful differentiation between genuine pluralism and pathological diffusion, with the therapeutic task aimed at fostering an internalized and stable framework for moral and cultural self-definition.

Disturbances in Body Image

Akhtar later expanded his account of identity diffusion to include disturbances in body image as an additional hallmark. A cohesive identity ordinarily entails a stable and realistic body image: an inner sense of embodiment that aligns with one’s lived physical self. In individuals with identity diffusion, however, this image is often fragmented, distorted, or unstable. The body may be experienced alternately as alien, deficient, exaggerated, or even absent, paralleling the broader discontinuities in self-experience. Such distortions not only heighten vulnerability to psychosomatic preoccupations, eating disorders, or dysmorphophobic anxieties, but also undermine the capacity for embodied self-cohesion that anchors authenticity and continuity of identity.

The Phenomenology of Disturbed Identity: Jørgensen & Bøye’s Study

A major recent contribution to the study of identity diffusion is the qualitative investigation by Carsten Jørgensen and Rikke Bøye, How Does It Feel to Have a Disturbed Identity? (2022). While identity diffusion has long been recognized as a central feature of borderline personality disorder (BPD), its actual phenomenology (the way it is lived and experienced by patients) has remained surprisingly underexplored. Jørgensen and Bøye address this gap by conducting in-depth interviews with sixteen women diagnosed with BPD using the SCID-5, analyzed through interpretative phenomenological analysis (IPA).

The authors begin by situating identity diffusion within contemporary nosology. Both DSM-5 and ICD-11 elevate disturbances of identity to a central diagnostic position, extending beyond BPD to the broader spectrum of personality disorders. Kernberg’s structural model, as noted above, has long emphasized identity diffusion as the decisive marker of BPO. Yet diagnostic systems often state the criterion abstractly, leaving clinicians with little guidance on what disturbed identity actually looks and feels like. Jørgensen and Bøye’s study attempts to fill that void by privileging patients’ first-person accounts.

The sample consisted of relatively young women (mean age 27.6), most with significant comorbidities and high levels of symptom severity, as reflected in standardized measures like the Inventory of Personality Organization (IPO) and Self-Concept and Identity Measure (SCIM). The interview protocol was carefully constructed to probe core domains of identity functioning, drawing on Akhtar’s descriptive categories, Kernberg’s theory, DSM-5 criteria, and prior empirical studies.

Patients were asked how they would describe themselves, how they felt in solitude and in company, their experience of social belonging, future orientation, and sexuality. The authors emphasized open-ended exploration over structured checklists, in keeping with the phenomenological aim of capturing lived experience.

From these interviews, nine superordinate themes emerged:

  1. Fluctuating and Disintegrated Self-Image. All participants described painful uncertainty about “who I am.” Their self-concept shifted with mood or social context, leaving them unable to articulate a stable sense of identity. Some described feeling that “there is no me,” others that they were defined only by the expectations of others.

  2. Masks and Façades. Most patients reported adopting external roles, appearances, or behaviors to stabilize themselves or to gain acceptance. These façades could take the form of clothing, makeup, humor, or role-playing. While sometimes consciously constructed, they often operated automatically, producing feelings of inauthenticity and self-alienation.

  3. Brokenness and Defectiveness. A pervasive sense of being damaged, incomplete, or fundamentally wrong emerged. Patients often used metaphors of broken machines, cracked porcelain, or missing puzzle pieces. This self-perception was closely linked to shame, low self-worth, and fears of rejection.

  4. Failure of Social Belonging. Most participants described feeling excluded, marginal, or “the black sheep.” Even when superficially integrated into groups, they felt inauthentic and alienated. For some, this produced active avoidance of communities; for others, futile attempts to adapt by mimicry.

  5. Emptiness and Meaninglessness. Nearly all participants conveyed profound inner emptiness, often described as a void, shell, or black hole. This emptiness was distinct from loneliness: it was an absence of inner substance, not just the absence of others. It was accompanied by boredom, insignificance, and a sense of wasting one’s life.

  6. Lack of Agency and Future Orientation. Participants frequently reported not knowing what they wanted, being unable to make choices, or lacking long-term goals. The future appeared foggy or nonexistent, with some preferring to avoid planning altogether to avert disappointment.

  7. Reliance on Others to Stabilize the Self. Many patients described needing others to feel that they existed at all. Being alone intensified feelings of emptiness; being with others provided a fragile sense of reality, though often temporary and unstable.

  8. Relational Paradox. Participants simultaneously longed for closeness and feared it. Relationships were pursued desperately but often felt overwhelming, unfulfilling, or fraught with fears of abandonment.

  9. Sexuality as Self-Regulation. A majority described using sex as a way to manage distress, seek validation, or distract from painful self-states. Sexual encounters were often detached from intimacy, serving primarily defensive or regulatory functions.

This thematic structure resonates strongly with earlier psychoanalytic descriptions of identity diffusion. Deutsch’s “as if” personality, Winnicott’s “false self,” Horney’s neurotic “shoulds,” and Akhtar’s catalogue of contradictions all find echoes here. Yet Jørgensen and Bøye add the indispensable voice of patients themselves, grounding these theoretical constructs in lived experience. Their accounts vividly demonstrate how identity diffusion is not simply a cognitive deficit, but a painful, embodied way of being in the world: unstable, inauthentic, fragmented, and profoundly lonely.

Clinically, the study underscores the importance of attending to these subjective dimensions rather than reducing identity disturbance to checklist criteria. The women’s testimonies remind us that identity diffusion is not an abstraction, but a daily struggle marked by brokenness, emptiness, and desperate attempts at stabilization. Treatment must therefore move beyond symptom reduction to address the structural integration of identity, supporting patients in constructing continuity, authenticity, and belonging.

Treatment Implications

The clinical task with patients suffering from identity diffusion is not only to interpret unconscious dynamics but also to help them gradually establish continuity, authenticity, and a coherent sense of self. This requires a stance of empathetic confrontation: drawing attention to contradictions in a manner that is compassionate rather than shaming. Empathy involves seeing the full person, in all their complexity, difficulties, struggles, angst, emptiness, and hardships. Confrontation may seem opposed to empathy, yet it serves as a compassionate search for truth—a deepening of the patient’s reflective functioning around life portions obscured by shame-fueled denial or repression. Patients who rely heavily on splitting will often react to the most recent interaction while disavowing or ignoring previous behavior. Simply pointing out discrepancies can be destabilizing; instead, the therapist should bring them into awareness with empathy, framing the contradiction as understandable given the patient’s inner fragmentation. In this way, the clinician models reflective functioning, enabling the patient to tolerate ambivalence and integrate disowned aspects of self and other.

Lack of temporal continuity presents another therapeutic challenge. Kernberg (2008) emphasized that the repetition compulsion (an effort to secure the idealized object and undo past trauma) prevents the accumulation of new experiences that could stabilize a life narrative. Patients may feel trapped in a perpetual present, disconnected from both their past and their future selves. Interventions here should focus on shifting the patient out of reenactments and toward the internalization of healthier relational experiences. Enactments will also happen in sessions with you, their therapist, and they may even project into you aspects of their traumatic upbringing that might draw you into uncharted waters for your normal behavior, thoughts and fantasies, or you may notice disruptions in the frame. Supervision will help in case you find yourself in rough waters. Each moment of reliable attunement in the therapeutic relationship becomes a building block for a more cohesive sense of identity, gradually interrupting the cycle of repetition and opening space for continuity.

Authenticity, too, is a central therapeutic aim. Patients with identity diffusion often struggle to distinguish between healthy forms of identification (such as aspiring to embody a valued mentor) and pathological mimicry aimed at filling an inner void. The clinician’s role is to listen closely for authentic notes, even when faint–perhaps in a patient’s firm refusal, a deeply felt boundary, or a glimpse of personal value. Sometimes these come through in art, writing, poetry, microexpressions, bodily sensations, or dreams. Attuning to these moments with curiosity and compassion can help strengthen the patient’s authentic voice, buried as it often is under shame, dissociation, or compulsive compliance. Therapy thus becomes a process of amplifying these fragile but genuine signals of selfhood.

The experience of chronic emptiness also requires careful clinical handling. Patients may attempt to “fill the container” through acting out, compulsive behaviors, or self-destructive pursuits. Such actions are less about desire than about warding off the intolerable void of non-being. Here, the therapist’s task is to hold the emptiness in mind without rushing to fill it, offering containment and interpretation of how such behaviors function to avoid the terror of inner hollowness. By tolerating this emptiness alongside the patient, the therapist helps transform it into an experience that can be thought about rather than compulsively enacted. 

Working with such patients often evokes intense countertransference reactions. Therapists may find themselves feeling uncertain about who the patient “really is,” or even questioning their own competence despite feeling capable with other patients. You may feel dissociated yourself: a haze or fog in the room for some, boredom for others, or frustration and hopelessness. These reactions, far from being obstacles, can be invaluable sources of empathy and clinical information. They mirror the disorientation others may feel in relation to the patient and can guide the therapist in making the patient’s relational impact explicit. By using countertransference as a compass, the therapist gains a fuller understanding of the patient’s interpersonal world and can offer interpretations grounded in lived experience.

Conclusion

In sum, treatment of identity diffusion demands a careful balance: confronting contradictions without shaming, fostering temporal continuity, amplifying moments of authenticity, and tolerating emptiness without acting to fill it prematurely. Success depends less on brilliant interpretations than on the steady provision of a relationship that is at once attuned, stable, and curious–a context in which the patient can gradually weave together a fragmented self into a more coherent whole.

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