I Hate You—Don't Leave Me (31 page)

In the late 1920s and early 1930s, the followers of the British psychoanalyst Melanie Klein investigated the cases of many patients who seemed just beyond the reach of psychoanalysis. The Kleinians focused on psychological dynamics as opposed to biological-constitutional factors.

The term
borderline
was first coined by Adolph Stern in 1938 to describe a group of patients who did not seem to fit into the primary diagnostic classifications of “neuroses” and “psychoses.”
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These individuals were obviously more ill than neurotic patients—in fact, “too ill for classical psychoanalysis”—yet they did not, like psychotic patients, continually misinterpret the real world. Though, like neurotics, they displayed a wide range of anxiety symptoms, neurotic patients usually had a more solid, consistent sense of identity and used more mature coping mechanisms.

Throughout the 1940s and 1950s, other psychoanalysts began to recognize a population of patients who did not fit existing pathological descriptions. Some patients appeared to be neurotic or mildly symptomatic, but when they engaged in traditional psychotherapy, especially psychoanalysis, they “unraveled.” Similarly, hospitalization would also exacerbate symptoms and increase the patient's infantile behavior and dependency on the therapist and hospital.

Other patients would appear to be severely psychotic, often diagnosed schizophrenic, only to make a sudden and unexpected recovery within a very short time. (Such dramatic improvement is inconsistent with the usual course of schizophrenia.) Still other patients exhibited symptoms suggestive of depression, but their radical swings in mood did not fit the usual profile of depressive disorders.

Psychological testing also confirmed the presence of a new, unique classification. Certain patients performed normally on structured psychological tests (such as IQ tests), but on unstructured, projective tests requiring narrative personalized responses (such as the Rorschach inkblot test), their responses were much more akin to those of psychotic patients, who displayed thinking and fantasizing on a more regressed, more childlike level.

During this postwar period, psychoanalysts fastened onto different aspects of the syndrome, seeking to develop a succinct delineation. In many ways the situation was like the old tale of the blind men who stood around an elephant and touched its various anatomical parts, trying to identify them. Each man described a different animal, of course, depending on which part he touched. Similarly, researchers were able to touch and identify different aspects of the borderline syndrome but could not quite see the whole organism. Many researchers (Zilboorg, Hoch and Polatin, Bychowski, and others)
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and DSM-II (1968)
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rallied around the schizophrenia-like aspects of the disorder, using such terms as “ambulatory schizophrenia,” “pre-schizophrenia,” “pseudoneurotic schizophrenia,” and “latent schizophrenia” to describe the illness. Others concentrated on these patients' lack of a consistent, core sense of identity. In 1942, Helene Deutsch described a group of patients who overcame an intrinsic sense of emptiness by a chameleon-like altering of their internal and external emotional experiences to fit the people and situations they were involved with at the moment. She termed this tendency of adopting the qualities of others as a means of gaining or retaining their love the “as-if personality.”
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In 1953, Robert Knight revitalized the term
borderline
in his consideration of “borderline states.”
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He recognized that, even though certain patients presented markedly different symptoms and were categorized with different diagnoses, they were expressing a common pathology.

After Knight's work was published, the term
borderline
became more popular, and the possibility of using Stern's general borderline concept as a diagnosis became more acceptable. In 1968, Roy Grinker and his colleagues defined four subtypes of the borderline patient: (1) a severely afflicted group who bordered on the psychotic; (2) a “core borderline” cluster with turbulent interpersonal relationships, intense feeling states, and loneliness; (3) an “as-if” group easily influenced by others and lacking in stable identity; and (4) a mildly impaired set with poor self-confidence and bordering on the neurotic end of the spectrum.
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Yet, even with all this extensive pioneering research, the diagnosis of borderline personality, among working clinicians, was still drenched in ambiguity. It was considered a “wastebasket diagnosis” by many, a place to “dump” those patients who were not well understood, who resisted therapy, or who simply did not get better; the situation remained that way well into the 1970s.

As borderline personality became more rigorously defined and distinguishable from other syndromes, attempts were made to change the ambiguous name. At one point, “unstable personality” was briefly considered during the development of DSM-III. However, borderline character pathology is relatively fixed and invariable (at least for a considerable period) despite its chaos—it is predictably stable in its instability. No other names have been prominently proposed as a replacement.

In the 1960s and 1970s, two major schools of thought evolved to delineate a consistent set of criteria for defining the borderline syndrome. Like some other disciplines in the natural and social sciences, psychiatry was split ideologically into two primary camps—one more concept oriented, the other more influenced by descriptive, observable behavior that could be more easily retested and studied under laboratory conditions.

The empirical school, led by John G. Gunderson of Harvard and favored by many researchers, developed a structured, more behavioral definition, one based on observable criteria and thus more accessible to research and study. This definition is the most widely accepted and in 1980 was adopted by DSM-III and perpetuated in DSM-IV (see chapter 2).

The other more concept-oriented school, led by Otto Kernberg of Cornell and favored by many psychoanalysts, proposes a more psychostructural approach that describes the syndrome based on intrapsychic functioning and defense mechanisms rather than overt behaviors.

In 1967, Otto Kernberg introduced his concept of Borderline Personality Organization (BPO), a broader concept than the current DSM-IV's Borderline Personality Disorder. Kernberg's conceptualization places BPO midway between neurotic and psychotic personality organization.
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A patient with BPO, as defined by Kernberg, is less impaired than a psychotic, whose perceptions of reality are severely contorted, making normal functioning impossible. On the other hand, the borderline is more disabled than a person with neurotic personality organization, who experiences intolerable anxiety as a result of emotional conflicts. The neurotic's perception of identity and system of defense mechanisms are usually more adaptive than those of the borderline.

BPO encompasses other Axis II, or characterological disorders, such as paranoid, schizoid, antisocial, histrionic, and narcissistic personality disorders. In addition, it includes obsessive-compulsive and chronic anxiety disorders, hypochondriasis, phobias, sexual perversions, and dissociative reactions (such as dissociative identity disorder—also known as multiple personality disorder). In Kernberg's system, patients currently diagnosed with BPD would constitute only about 10 to 25 percent of patients classified BPO. A patient diagnosed with BPD is conceived as occupying a lower functioning, higher severity level within the overall BPO diagnosis.

Though Kernberg's system was not officially adopted by the APA, his work has had (and continues to have) significant influence as a theoretical model for both clinicians and researchers. In general, Kernberg's schema emphasizes the inferred internal mechanisms discussed below.

Like neurotics, borderlines retain contact with reality most of the time; however, under stress the borderline can regress to a brief psychotic state. Marjorie, a twenty-nine-year-old married woman, sought therapy for increasing depression and marital disharmony. An intelligent, attractive woman, Marjorie related calmly throughout her initial eight sessions. She eagerly assented to a joint interview with her husband, but during the session she turned uncharacteristically loud and belligerent. Dropping her facade of self-control, she began to berate her husband for alleged infidelities. She accused her therapist of taking her husband's side (“You men always stick together!”) and accused both of engaging in a conspiracy against her. The sudden transformation from a relaxed, mildly depressed woman to a raging, paranoid one is quite characteristic of the kind of rapidly shifting borders of reality observed in the borderline.

Borderlines have great difficulty tolerating frustration and coping with anxiety. In Kernberg's framework, impulsive behavior is an attempt to diffuse this tension. Borderlines also have defective sublimation tools; that is, they are unable to channel frustrations and discomforts in socially adaptive ways. Though borderlines may exhibit extreme empathy, warmth, and guilt, these exhibitions are often rote, more manipulative gestures for display purposes only, rather than true expressions of feeling. Indeed, the borderline may act as if he has totally forgotten a dramatic effusion that occurred only moments before, much like a child who suddenly emerges from a temper tantrum all smiles and laughter.

Borderlines are capable of performing well in a structured work or professional environment, but below the surface linger grave self-doubts, suspicions, and fears. The internal thought processes of borderlines may be surprisingly unsophisticated and primal, camouflaged by a stable facade of learned and rehearsed platitudes. Any circumstance that pierces the protective structure shielding the borderline may unleash a flood of chaotic passions concealed within. The example of Marjorie (above) illustrates this point.

Projective psychological tests also reveal the borderline's primitive thought processes. These tests—such as the Rorschach and Thematic Apperception Test (TAT)—elicit associations to ambiguous stimuli, such as inkblots or pictures, around which the patient creates a story. Borderline responses typically resemble those of schizophrenics and other psychotic patients. Unlike the coherent, organized responses usually observed among neurotic patients, those from borderlines often describe bizarre, primitive images—the borderline might see vicious animals cannibalizing one another, where the neurotic sees a butterfly.

The coping mechanism of splitting (see chapter 2) preserves the borderline's perception of a world of extremes—a view in which people and objects are either good or bad, friendly or hostile, loved or hated—in order to escape the anxiety of ambiguity and uncertainty.

In Kernberg's conceptualization, splitting often leads to “magical thinking”: superstitions, phobias, obsessions, and compulsions are used as talismans to ward off unconscious fears. Splitting also results in derivative defense mechanisms:

For example, Mark, a young, married man who is diagnosed as borderline, finds his own sadistic and angry impulses unacceptable and projects them onto his wife, Sally. Sally is then perceived by Mark (in his black-and-white fashion) to be a “totally angry woman.” All of her actions are interpreted as sadistic. He unconsciously “pushes her buttons” to extract angry responses, thus confirming his projections. In this way, Mark fears yet simultaneously controls his perception of Sally.

“Identity diffusion” describes Kernberg's conception of the borderline's lack of a stable, core sense of identity. The borderline's identity is the consistency of Jell-O: it can be molded into any configuration that contains it, but slips through the hands when you try to pick it up. This lack of substance leads directly to the identity disturbances outlined in criterion 3 of DSM-IV's description of BPD (see chapter 2).

As “identity diffusion” describes the borderline's lack of a stable concept of self, “object inconstancy” describes the lack of a stable concept of others. Just as his own self-esteem depends on current circumstances, the borderline bases his attitude toward another person on the most recent encounter, rather than on a more stable and enduring perception grounded in a consistent, connected series of experiences.

Often, the borderline is unable to hold on to the memory of a person or object when he, she, or it is not present. Like a child who becomes attached to a transitional object that represents a soothing mother figure (such as Linus's attachment to his blanket in the
Peanuts
cartoons), the borderline uses objects, such as pictures and clothing, to simulate the presence of another person. For example, when a borderline is separated from home for even a brief period, he typically takes many personal objects as soothing reminders of familiar surroundings. Teddy bears and other stuffed animals accompany him to bed, and snapshots of family are carefully placed around the room. If he is left home while his wife is away, he often stares longingly at her picture and her closet, and smells her pillow, seeking the comfort of familiarity.