I Hate You—Don't Leave Me (30 page)

As the borderline forges a distinct, core sense of identity, he also differentiates himself from others. Change requires the appreciation of others as independent persons and the empathy to understand their struggles. Their flaws and imperfections must not only be acknowledged but also understood as separate from the borderline himself, part of the process of mentalization (see chapter 8). When this task fails, relationships falter. Princess Diana mourned the loss of her fantasy of a fairy-tale marriage to Prince Charles: “I had so many dreams as a young girl. I wanted, and hoped . . . that my husband would look after me. He would be a father figure, and he'd support me, encourage me. . . . But I didn't get any of that. I couldn't believe it. I got none of that. It was role reversal.”
¹

The borderline must learn to integrate the positive and negative aspects of other individuals. When the borderline wants to get close to another person, he must learn to be independent enough to be dependent in comfortable, not desperate, ways. He learns to function symbiotically, not parasitically. The healing borderline develops a constancy about himself and about others; trust—of others and of his own perceptions—develops. The world becomes more balanced, more in between.

Just as in climbing a mountain, the fullest experience comes when the climber can appreciate all the vistas: to look up and keep his goal firmly in view, to look down and recognize his progress as he proceeds. And finally, to rest, look around, and admire the view from right where he is at the moment. Part of the experience is recognizing that no one ever reaches the pinnacle; life is a continuous climb up the mountain. A good deal of mental health is being able to appreciate the journey—to be able to grasp the Serenity Prayer invoked at most twelve-step meetings: “God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

When an individual first enters therapy, he often does not understand that it is
he
, not others, who must make changes. However, when he does make changes, important people in his life must also adjust. Stable relationships are dynamic, fluctuating systems that have attained a state of equilibrium. When one person in that system makes significant changes in his ways of relating, others must adjust in order to recapture homeostasis, a state of balance. If these readjustments do not occur, the system may collapse and the relationships may shatter.

For example, Alicia consults a psychotherapist for severe depression and anxiety. In therapy, she rails against her alcoholic husband, Adam, whom she blames for her feelings of worthlessness. Eventually she recognizes her own role in the crumbling marriage—her own need to have others become dependent upon her, her reciprocal need to shame them, and her fears of reaching for independence. She begins to blame Adam less. She develops new, independent interests and relationships. She stops her crying episodes; she stops initiating fights over his drinking; the equilibrium of the marriage is altered.

Adam may now find that the situation is much more uncomfortable than it was before. He may escalate his drinking in an unconscious attempt to reestablish the old equilibrium and compel Alicia to return to her martyred, caretaking role. He may accuse her of seeing other men and try to disrupt their relationship, now intolerable to him.

Or, he too can begin to see the necessity for change and his own responsibility in maintaining this pathological equilibrium. He may take the opportunity to see his own actions more clearly and reevaluate his own life, just as he has seen his wife do.

Participation in therapy may be a valuable experience for everyone affected. The more interesting and knowledgeable Elizabeth became, the more ignorant her husband seemed to her. The more opened-minded she became—the more gray she was able to perceive in a situation—the more black and white he became in order to reestablish equilibrium. She felt that she was “leaving someone behind.” That person was her—or, more closely, a part of her she no longer needed or wanted. She was, in her words, “growing up.”

As Elizabeth's treatment wound down, she met less regularly with her doctor, yet still had to contend with other important people in her life. She fought with her brother, who refused to own up to his drug problem. He accused her of being “uppity,” of “using her new psychological crap as ammunition.” They argued bitterly over the lack of communication within the family. He told her that even after all the “shrinks,” she was still “screwed up.” She fought with her mother, who remained demanding, complaining, and incapable of showing her any love. She contended with her husband, who professed his love but continued to drink heavily and criticize her desire to pursue her education. He refused to help with their son and after a while she suspected his frequent absences were related to an affair with another woman.

Finally, Elizabeth began to recognize that she did not have the power to change others. She utilized SET techniques to try to better understand these family members and maintain protective boundaries for herself, which could shield her from being pulled into further conflicts. She began to accept them for who they were, love them as best she could, and go on with her own life. She recognized the need for new friends and new activities in her life. Elizabeth called this “going home.”

DSM-IV-TR Classifications

The
Diagnostic and Statistical Manual of Mental Disorders
, Fourth Edition, Text Revision (DSM-IV-TR), was published by the American Psychiatric Association in 2000. This work attempts to evaluate psychiatric illnesses along five axes.

(Partial listing with some examples)

 

Learning Disorder

Attention Deficit/Hyperactivity Disorder

Autism

Tourette's

 

Substance Intoxication Delirium

Alzheimer's

Dementia Due to Head Trauma

 

Alcoholism

Cocaine Abuse

Cannabis Abuse

Amphetamine Abuse

Hallucinogen Intoxication

 

Schizophrenia

 

Major Depressive Disorder

Dysthymic Disorder

Bipolar I Disorder

Bipolar II Disorder

 

Panic Disorder

Phobia

Post-Traumatic Stress Disorder

Social Anxiety Disorder

Obsessive-Compulsive Disorder

Generalized Anxiety Disorder

 

Somatization Disorder

Hypochondriasis

Conversion Disorder

Body Dysmorphic Disorder

 

 

Dissociative Identity Disorder (Multiple Personality)

Dissociative Amnesia

Dissociative Fugue

 

Premature Ejaculation

Vaginismus

Exhibitionism

Pedophilia

Fetishism

 

Anorexia Nervosa

Bulimia Nervosa

 

Primary Insomnia

Sleepwalking Disorder

 

Intermittent Explosive Disorder

Kleptomania

Pathological Gambling

Trichotillomania (hair or eyebrow pulling)

 

With Depressed Mood

With Anxiety

(Complete listing)

 

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

 

Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

 

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

Our current nomenclature defining BPD relies on fulfilling a threshold of descriptive symptoms listed in the APA's DSM-IV-TR: An individual
has
BPD if he exhibits at least five of the nine criteria (see chapter 2). Thus, the person who reflects, say, five symptoms and is then able to eliminate just one is immediately relieved of the diagnosis.

This
categorical
paradigm, however, does not reflect the traditional perception of personality, which is that personality is not altered so abruptly. Thus, it is highly likely that future DSM definitions of BPD will integrate
dimensional
features. In this paradigm the
degree
of functioning or disability may be considered. More specifically, the doctor will be able to factor into an evaluation the
degree
of specific characteristics (such as impulsiveness, emotional lability, reward dependence, harm avoidance, etc.)—not just the
presence
of these symptoms—to diagnose (or not diagnose) BPD. The intent of such DSM changes is that these adaptations will more accurately measure changes and degrees of improvement, rather than merely determine the presence or absence of the disorder.

Evolution of the Borderline Syndrome

The concept of the borderline personality has evolved primarily through the theoretical formulations of psychoanalytic writers. Current DSM-IV-TR criteria—observable, objective, and statistically reliable principles for defining this disorder—are derived from the more abstract, speculative writings of psychoanalytic theorists over the past hundred years.

During Sigmund Freud's era at the turn of the century, psychiatry was a branch of medicine closely aligned with neurology. Psychiatric syndromes were defined by directly observable behaviors, as opposed to unobservable, mental, or “unconscious” mechanisms, and most forms of mental illness were attributed to neurophysiological aberrations.

Though Freud himself was an experienced neurophysiologist, he explored the mind through different portals. He developed the concept of the unconscious and initiated a legacy of psychological—rather than physiological—exploration of human behavior. Yet he remained convinced that physiological mechanisms would eventually be uncovered to coincide with his psychological theories.

Over a century after Freud's landmark work, we have come almost full circle: today, diagnostic classifications are once again defined by observable phenomena, and new frontiers of research into BPD and other types of mental illness are again exploring neurophysiological factors, while acknowledging the impact of psychological and environmental factors.

Freud's explication of the unconscious mind is the underpinning of psychoanalysis. He believed that psychopathology resulted from the conflict between primitive, unconscious impulses and the conscious mind's need to prevent these abhorrent, unacceptable thoughts from entering awareness. He first used hypnosis, and later “free association” and other classical psychoanalytical techniques, to explore his theories.

Ironically, Freud intended classical psychoanalysis to be primarily an investigative tool rather than a form of treatment. His colorful case histories—“The Rat Man,” “The Wolf Man,” “Little Hans,” “Anna O,” etc.—were published to support his evolving theories as much as to promote psychoanalysis as a treatment method. Many current psychiatrists believe that these patients, whom Freud felt exhibited hysteria and other types of neuroses, would today clearly be identified as borderline.

Psychoanalysts who followed Freud were the main contributors to the modern concept of the borderline syndrome.
¹
In 1925, Wilhelm Reich's
Impulsive Character
described attempts to apply psychoanalysis to certain unusual characterological disorders that he encountered in his clinic. He found that the “impulsive character” was often immersed in two sharply contradictory feeling states at the same time, but was able to maintain the states without apparent discomfort via the splitting mechanism—a concept that has become central to all subsequent theories on the borderline syndrome, particularly Kernberg's (see page 234).