I Hate You—Don't Leave Me (3 page)

He is Brett, your next-door neighbor. Unable to come to grips with his collapsing marriage, he denies his wife's obvious unfaithfulness in one breath, and then takes complete blame for it in the next. He clings desperately to his family, caroming from guilt and self-loathing to raging attacks on his wife and children who have so “unfairly” accused him.

If the people in these short profiles seem inconsistent, it should not be surprising—inconsistency is the hallmark of BPD. Unable to tolerate paradox, borderlines are walking paradoxes, human catch-22s. Their inconstancy is a major reason why the mental health profession has had such difficulty defining a uniform set of criteria for the illness.

If these people seem all too familiar, this also should not be surprising. The chances are good that you have a spouse, relative, close friend, or coworker who is borderline. Perhaps you know a little bit about BPD or recognize borderline characteristics within yourself.

Though it is difficult to get a firm grasp on the figures, mental health professionals generally agree that the number of borderlines in the general population is growing—and at a rapid pace—though some observers claim that it is the therapists' awareness of the disorder that is growing rather than the number of borderlines.

Is borderline personality really a modern-day “plague,” or is merely the diagnostic label
borderline
new? In any event, the disorder has provided new insight into the psychological framework of several related conditions. Numerous studies have linked BPD with anorexia, bulimia, ADHD, drug addiction, and teenage suicide—all of which have increased alarmingly over the last decade. Some studies have uncovered BPD in almost 50 percent of all patients admitted to a facility for an eating disorder.
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Other studies have found that over 50 percent of substance abusers also fulfill criteria for BPD.

Self-destructive tendencies or suicidal gestures are very common among borderlines—indeed, they are one of the syndrome's defining criteria. As many as 70 percent of BPD patients attempt suicide. The incidence of documented death by suicide is about 8 to 10 percent and even higher for borderline adolescents. A history of previous suicide attempts, a chaotic family life, and a lack of support systems increase the likelihood. The risk multiplies even more among borderline patients who also suffer from depressive or manic-depressive (bipolar) disorders, or from alcoholism or drug abuse.
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Before 1980, the previous two editions of the DSM described psychiatric illnesses in descriptive terms. However, DSM-III defined psychiatric disorders along structured,
categorical
paradigms; that is, several symptoms have been proposed to be suggestive of a particular diagnosis, and when a certain number of these criteria are met, the individual is considered to fulfill the categorical requirements for diagnosis. Interestingly, in the four revisions of DSM since 1980, only minor adjustments have been made to the definitional criteria for BPD. As we shall see shortly, nine criteria are associated with BPD, and an individual qualifies for the diagnosis if he exhibits five or more of the nine.

The categorical paradigm has stimulated controversy among psychiatrists, especially regarding the diagnosis of personality disorders. Unlike most other psychiatric illnesses, personality disorders are generally considered to develop in early adulthood and to persist for extended periods. These personality traits tend to be enduring and change only gradually over time. However, the categorical system of definitions may result in an unrealistically abrupt diagnostic change. In relation to BPD, a borderline patient who exhibits five symptoms of BPD theoretically ceases to be considered borderline if one symptom changes. Such a precipitous “cure” seems inconsistent with the concept of personality.

Some researchers have suggested adjusting the DSM to a
dimensional
approach to diagnosis. Such a model would attempt to determine what could be called “degrees of borderline,” since clearly some borderlines function at a higher level than others. These authors suggest that, rather than concluding that an individual is—or is not—borderline, the disorder should be recognized along a spectrum. This approach would put different weights on some of the defining criteria, depending upon which symptoms are shown by research to be more prevalent and enduring. Such a method could develop a representative, “pure” borderline prototype, which could standardize measures based on how closely a patient “matches” the description. A dimensional approach might be used to measure functional impairment. In this way, a higher or lower functioning borderline would be identified by her ability to manage her usual tasks of living. Another methodology would gauge particular traits, such as impulsivity, novelty-seeking, reward dependence, harm avoidance, neuroticism (capturing such characteristics as vulnerability to stress, poor impulse control, anxiety, mood lability, etc.) that have been associated with BPD.
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Such adaptations may more accurately measure changes and degrees of improvement, rather than merely determining the presence or absence of the disorder.

To understand the difference between these two definitional approaches, consider the way we perceive “gender.” The determination that one is male or female is a
categorical
definition, based on objective genetic and hormonal factors. Designations of masculinity or femininity, however, are
dimensional
concepts, influenced by personal, cultural, and other less objective criteria. It is likely that future iterations of the DSM will incorporate dimensional features of diagnosis.

The most recent DSM-IV-TR lists nine categorical criteria for BPD, five of which must be present for diagnosis.
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At first glance, these criteria may seem unconnected or only peripherally related. When explored in depth, however, the nine symptoms are seen to be intricately connected, interacting with each other so that one symptom sparks the rise of another like the pistons of a combustion engine.

The nine criteria may be summarized as follows (each is described in depth in chapter 2):

This constellation of nine symptoms can be grouped into four primary areas toward which treatment is frequently directed:

Beneath the clinical nomenclature lies the anguish experienced by borderlines and their families and friends. For the borderline, much of life is a relentless emotional roller coaster with no apparent destination. For those living with, loving, or treating the borderline, the trip can seem just as wild, hopeless, and frustrating.

Jennifer and millions of other borderlines are provoked to rage uncontrollably against the people they love most. They feel helpless and empty, with an identity splintered by severe emotional contradictions.

Mood changes come swiftly, explosively, carrying the borderline from the heights of joy to the depths of depression. Filled with anger one hour, calm the next, he often has little inkling about why he was driven to such wrath. Afterward, the inability to understand the origins of the episode brings on more self-hate and depression.

A borderline suffers a kind of “emotional hemophilia”; she lacks the clotting mechanism needed to moderate her spurts of feeling. Prick the delicate “skin” of a borderline and she will emotionally bleed to death. Sustained periods of contentment are foreign to the borderline. Chronic emptiness depletes him until he is forced to do anything to escape. In the grip of these lows, the borderline is prone to a myriad of impulsive, self-destructive acts—drug and alcohol binges, eating marathons, anorexic fasts, bulimic purges, gambling forays, shopping sprees, sexual promiscuity, and self-mutilation. He may attempt suicide, often not with the intent to die but to feel
something
, to confirm he is alive.

“I hate the way I feel,” confesses one borderline. “When I think about suicide, it seems so tempting, so inviting. Sometimes it's the only thing I relate to. It is difficult not to want to hurt myself. It's like, if I hurt myself, the fear and pain will go away.”

Central to the borderline syndrome is the lack of a core sense of identity. When describing themselves, borderlines typically paint a confused or contradictory self-portrait, in contrast to other patients who generally have a much clearer sense of who they are. To overcome their indistinct and mostly negative self-image, borderlines, like actors, are constantly searching for “good roles,” complete “characters” they can use to fill their identity void. So they often adapt like chameleons to the environment, situation, or companions of the moment, much like the title character in Woody Allen's film
Zelig
, who literally assumes the personality, identity, and appearance of people around him.

The lure of ecstatic experiences, whether attained through sex, drugs, or other means, is sometimes overwhelming for the borderline. In ecstasy, he can return to a primal world where the self and the external world merge—a form of second infancy. During periods of intense loneliness and emptiness, the borderline will go on drug binges, bouts with alcohol, or sexual escapades (with one or several partners), sometimes lasting days at a time. It is as if when the struggle to find identity becomes intolerable, the solution is either to lose identity altogether or to achieve a semblance of self through pain or numbness.

The family background of a borderline is often marked by alcoholism, depression, and emotional disturbances. A borderline childhood is frequently a desolate battlefield, scarred with the debris of indifferent, rejecting, or absent parents, emotional deprivation, and chronic abuse. Most studies have found a history of severe psychological, physical, or sexual abuse in many borderline patients. Indeed, a history of mistreatment, witness to violence, or invalidation of experience by parents or primary caregivers distinguishes borderline patients from other psychiatric patients.
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These unstable relationships carry over into adolescence and adulthood, where romantic attachments are highly charged and usually short-lived. The borderline will frantically pursue a man (or woman) one day and send him packing the next. Longer romances—usually measured in weeks or months rather than years—are usually filled with turbulence and rage, wonder, and excitement.

The world of a borderline, like that of a child, is split into heroes and villains. A child emotionally, the borderline cannot tolerate human inconsistencies and ambiguities; he cannot reconcile another's good and bad qualities into a constant, coherent understanding of that person. At any particular moment, one is either “good” or “evil”; there is no in-between, no gray area. Nuances and shadings are grasped with great difficulty, if at all. Lovers and mates, mothers and fathers, siblings, friends, and psychotherapists may be idolized one day, totally devalued and dismissed the next.

When the idealized person finally disappoints (as we all do, sooner or later), the borderline must drastically restructure his strict, inflexible conceptualization. Either the idol is banished to the dungeon or the borderline banishes
himself
in order to preserve the “all-good” image of the other person.

This type of behavior, called “splitting,” is the primary defense mechanism employed by the borderline. Technically defined, splitting is the rigid separation of positive and negative thoughts and feelings about oneself and others; that is, the inability to synthesize these feelings. Most individuals can experience ambivalence and perceive two contradictory feeling states at one time; borderlines characteristically shift back and forth, entirely unaware of one emotional state while immersed in another.

Splitting creates an escape hatch from anxiety: the borderline typically experiences a close friend or relation (call him “Joe”) as two separate people at different times. One day, she can admire “Good Joe” without reservation, perceiving him as completely good; his negative qualities do not exist; they have been purged and attributed to “Bad Joe.” Other days, she can guiltlessly and totally despise “Bad Joe” and rage at his evil without self-reproach—for now his positive traits do not exist; he fully deserves the rage.

Intended to shield the borderline from a barrage of contradictory feelings and images—and from the anxiety of trying to reconcile those images—the splitting mechanism often and ironically achieves the opposite effect: the frays in the personality fabric become full-fledged rips; the sense of her own identity and the identities of others shift even more dramatically and frequently.

Despite feeling continually victimized by others, a borderline desperately seeks out new relationships; for solitude, even temporary aloneness, is more intolerable than mistreatment. To escape the loneliness, the borderline will flee to singles bars, the arms of recent pickups, somewhere—anywhere—to meet someone who might save her from the torment of her own thoughts. The borderline is constantly searching for Mr. Goodbar.