I Hate You—Don't Leave Me (4 page)

In the relentless search for a structured role in life, the borderline is typically attracted to—and attracts to her—others with complementary personality traits. The domineering, narcissistic personality of Jennifer's husband, for example, cast her in a well-defined role with little effort. He was able to give her an identity even if the identity involved submissiveness and mistreatment.

Yet, for a borderline, relationships often disintegrate quickly. Maintaining closeness with a borderline requires an understanding of the syndrome and a willingness to walk a long, perilous tight-rope. Too much closeness threatens the borderline with suffocation. Keeping one's distance or leaving a borderline alone—even for brief periods—recalls the sense of abandonment he felt as a child. In either case, the borderline reacts intensely.

In a sense, the borderline is like an emotional explorer who carries only a sketchy map of interpersonal relations; he finds it extremely difficult to gauge the optimal psychic distance from others, particularly significant others. To compensate, he caroms back and forth from clinging dependency to angry manipulation, from gushes of gratitude to fits of irrational anger. He fears abandonment, so he clings; he fears engulfment, so he pushes away. He craves intimacy and is terrified of it at the same time. He winds up repelling those with whom he most wants to connect.

Though borderlines have extreme difficulties managing their personal lives, many are able to function productively in a work situation—particularly if the job is well structured, clearly defined, and supportive. Some perform well for long periods, but then suddenly—because of a change in the job structure, or a drastic shift in personal life, or just plain boredom and a craving for change—they abruptly leave or sabotage their position and go on to the next opportunity. Many borderlines complain of frequent or chronic minor medical illnesses, leading to recurrent doctor visits and sick days.
¹⁸

The work world can provide sanctuary from the anarchy of their social relationships. For this reason, borderlines frequently function best in highly structured work environments. The helping professions—medicine, nursing, clergy, counseling—also attract many borderlines who strive to achieve the power or control that elude them in social relationships. Perhaps more important, in these roles borderlines can provide the care for others—and receive the recognition from others—that they yearn for in their own lives. Borderlines are often very intelligent and display striking artistic abilities; fueled by easy access to powerful emotions, they can be creative and successful professionally.

But a highly competitive or unstructured job, or a highly critical supervisor, can trigger the intense, uncontrolled anger and the hypersensitivity to rejection to which the borderline is susceptible. The rage can permeate the workplace and literally destroy a career.

Until recently, studies suggested that women borderlines outnumbered men by as much as three or four to one. However, more recent epidemiological research confirms that prevalence is similar in both genders, although women enter treatment more frequently. Moreover, severity of symptoms and disability are greater among women. These factors may help explain why females have been overrepresented in clinical trials. But there may be other factors that contribute to the impression that BPD is a “woman's disease.”

Some critics feel that a kind of clinician bias operates with borderline diagnoses: Psychotherapists may perceive problems with identity and impulsivity as more “normal” in men; as a result, they may underdiagnose BPD among males. Where destructive behavior in women may be seen as a result of mood dysfunction, similar behavior in men may be perceived as antisocial. Where women in such predicaments may be directed toward treatment, men may instead be channeled through the criminal justice system where they may elude correct diagnosis forever.

Many of the features of the borderline syndrome—impulsivity, tumultuous relationships, identity confusion, mood instability—are major developmental hurdles for any adolescent. Indeed, establishing a core identity is the primary quest for both the teenager and the borderline. It follows, then, that BPD is diagnosed more commonly among adolescents and young adults than other age groups.
¹⁹

BPD appears to be rare in the elderly. Recent studies demonstrate that the greatest decline in diagnosis of BPD occurs after the mid-forties. From this data, some researchers hypothesize that many older borderline adults “mature out” and are able to achieve stabilization over time. However, elderly adults must contend with a progressive decline in physical and mental functioning, which can be a perilous adaptive process for some aging borderlines. For a fragile identity, the task of altering expectations and adjusting self-image can exacerbate symptoms. The aging borderline with persistent psychopathology may deny deteriorating functions, project the blame for deficiencies onto others, and become increasingly paranoid; at other times, he may exaggerate handicaps and become more dependent.

Borderline pathology has been identified in all cultures and economic classes in the United States. However, rates of BPD were significantly higher among those separated, divorced, widowed, or living alone, and among those with lower income and education. The consequences of poverty on infants and children—higher stress levels, less education, and lack of good child care, psychiatric care, and pregnancy care (perhaps resulting in brain insults or malnutrition)—might lead to higher incidence of BPD among the poor.

Although most of the theoretical formulations and empirical studies of the borderline syndrome have been conducted in the United States, other countries—Canada, Mexico, Israel, Sweden, Denmark, other Western European nations, and the former USSR—have recognized borderline pathologies within their populations.

Comparative studies are scant and contradictory at this point. For example, some studies indicate higher rates of BPD among Hispanics, while others do not confirm this finding. Some studies have found greater rates of BPD among Native American men. Consistent studies are meager but could provide great insight into the child-rearing, cultural, and social threads that compose the causal fabric of the syndrome.

Whether the borderline personality is a new phenomenon or simply a new label for a long-standing, interrelated cluster of internal feelings and external behaviors is a topic of some interest in the mental health community. Most psychiatrists believe that the borderline syndrome has been around for quite some time; that its increasing prominence results not so much from its spreading (like an infectious disease or a chronic debilitating condition) in the minds of patients but from the awareness of clinicians. Indeed, many psychiatrists believe that some of Sigmund Freud's most interesting cases of “neurosis” at the turn of the century would today be clearly diagnosed as borderline.
²⁰

Perceived in this way, the borderline syndrome becomes an interesting new perspective from which to understand some of our most complex personalities—both past and present, real and fictional. Conversely, well-known figures and characters can be understood to illustrate different aspects of the syndrome. Along these lines, biographers and others have speculated that the term might apply to such wide-ranging figures as Princess Diana, Marilyn Monroe, Zelda Fitzgerald, Thomas Wolfe, T. E. Lawrence, Adolf Hitler, and Muammar al-Gadhafi. Cultural critics can observe borderline features in Blanche Dubois in
A Streetcar Named Desire
, Martha in
Who's Afraid of Virginia Woolf?
, Sally Bowles in
Cabaret
, Travis Bickle in
Taxi Driver
, Howard Beale in
Network
, and Carmen in Bizet's opera. Although borderline symptoms or behaviors may be spotted in these characters, BPD should not be assumed to necessarily cause or propel the radical actions or destinies of these real people or the fictional characters or the works in which they appear. Hitler, for example, was probably driven by mental malfunctions and societal forces much more prominent in his psyche than BPD; the root causes of Marilyn Monroe's (alleged) suicide were probably more complex than to say simply it was caused by BPD. There is little evidence that the authors of
Taxi Driver
or
Network
were consciously trying to create a borderline protagonist. What the borderline syndrome does furnish is another perspective from which to interpret and analyze these fascinating personalities.

Since publication of the first edition of this book, significant strides have been made in research into the root causes of BPD and its treatment. Advances in our understanding of the biological, physiological, and genetic underpinnings of psychiatric diseases are exploding. Interactions between different parts of the brain and how emotions and executive reasoning intersect are being illuminated. The roles of neurotransmitters, hormones, and chemical reactions in the brain are better understood. Genetic vulnerability, how genes can be switched on and off, and the collision with life events to determine personality functioning are being studied. New psychotherapeutic techniques have evolved.

Long-term studies confirm that many patients recover over time and even more improve significantly. Over a decade 86 percent of borderline patients achieve sustained relief of symptoms, almost half of those within the first two years. However, despite diminution of defining symptoms, many of these patients continue to struggle in social and work or school environments. Although recurrence rates are as high as 34 percent, after ten years, full and complete recovery with good social and vocational functioning is achieved in 50 percent of patients.
^21
,
22
Many borderline patients improve without consistent treatment, although continued therapy hastens improvement.
²³

To one degree or another, we all struggle with the same issues as the borderline—the threat of separation, fear of rejection, confusion about identity, feelings of emptiness and boredom. How many of us have not had a few intense, unstable relationships? Or flew into a rage now and then? Or felt the allure of ecstatic states? Or dreaded being alone, or gone through mood swings, or acted in a self-destructive manner in some way?

If nothing else, BPD serves to remind us that the line between “normal” and “pathological” may sometimes be a very thin one. Do we all display, to one degree or another, some symptoms of borderline personality? The answer is probably yes. Indeed, many of you reading this first chapter might be thinking that this sounds like you or someone you know. The discriminating factor, however, is that not all of us are controlled by the syndrome to the degree that it disrupts—or rules—our lives. With its extremes of emotion, thought, and behavior, BPD represents some of the best and worst of human character—and of our society in the nascent years of the twenty-first century. By exploring its depths and boundaries, we may be facing up to our ugliest instincts and our highest potentials—and the hard road we must travel to get from one point to the other.

Chaos and Emptiness

All is caprice. They love without measure those whom they will soon hate without reason.

—Thomas Sydenham, seventeenth-century English physician, on “hystericks,” the equivalent of today's borderline personality

 

 

 

“I sometimes wonder if I'm possessed by the devil,” says Carrie, a social worker in the psychiatric unit of a large hospital. “I don't understand myself. All I know is, this borderline personality of mine has forced me into a life where I've cut everyone out. So it's very, very lonely.”

Carrie was diagnosed with the borderline syndrome after twenty-two years of therapy, medication, and hospitalizations for a variety of mental and physical illnesses. By then, her medical file resembled a well-worn passport, the pages stamped with the numerous psychiatric “territories” through which she had traveled.

“For years I was in and out of hospitals, but I never found a therapist who understood me and knew what I was going through.”

Carrie's parents were divorced when she was an infant, and she was raised by her alcoholic mother until she was nine. A boarding school took care of her for four years after that.

When she was twenty-one, overwhelming depression forced her to seek therapy; she was diagnosed and treated for depression at that time. A few years later, her moods began to fluctuate wildly and she was treated for bipolar disorder (manic depression). Throughout this period she repeatedly overdosed on medications and cut her wrists many times.

“I was cutting myself and overdosing on tranquilizers, antidepressants, or whatever drug I happened to be on,” she recalls. “It had become almost a way of life.”

In her mid-twenties, she began to have auditory hallucinations and became severely paranoid. At this time she was hospitalized for the first time and diagnosed schizophrenic.

And still later in life, Carrie was hospitalized in a cardiac-care unit numerous times for severe chest pains, subsequently recognized to be anxiety related. She went through periods of binge eating and starvation fasting; over a period of several weeks, her weight would vary by as much as seventy pounds.

When she was thirty-two, she was brutally raped by a physician on the staff of the hospital in which she worked. Soon after, she returned to school and was drawn into a sexual relationship with one of her female professors. By the age of forty-two, her collection of medical files was filled with almost every diagnosis imaginable, including schizophrenia, depression, bipolar disorder, hypochondriasis, anxiety, anorexia nervosa, sexual dysfunction, and post-traumatic stress disorder.