I Hate You—Don't Leave Me (6 page)

Post-traumatic stress disorder (PTSD) is a complex of symptoms that follows an extraordinarily severe traumatic event, such as a natural disaster or combat. It is characterized by intense fear, emotional re-experiencing of the event, nightmares, irritability, exaggerated startle response, avoidance of associated places or activities, and a sense of helplessness. Since both BPD and PTSD have frequently been associated with a history of extreme abuse in childhood and reflect similar symptoms—such as extreme emotional reactions and impulsivity—some have posited that they are the same illness. Although some studies indicate that they may occur together as much as 50 percent or more of the time, they are distinctly different disorders with different defining criteria.
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Many characteristics of BPD overlap with those of other personality disorders. For example, the dependent personality shares with the borderline the features of dependency, avoidance of being alone, and strained relationships. But the dependent personality lacks the self-destructiveness, anger, and mood swings of a borderline. Similarly, the schizotypal personality exhibits poor relations with others and difficulty in trusting, but is more eccentric and less self-destructive. Often a patient exhibits enough characteristics of two or more personality disorders to warrant diagnoses for each. For example, a patient may demonstrate characteristics that lead to diagnoses of both borderline personality disorder and obsessive-compulsive personality disorder.

In DSM-IV-TR, BPD is grouped in a cluster of personality disorders that generally reflect dramatic, emotional, or erratic features (see Appendix A). The others in this group are narcissistic, antisocial, and histrionic personality disorders, to which BPD is often compared.

Both borderlines and narcissists display hypersensitivity to criticism; failures or rejections can precipitate severe depression. Both exploit others; both demand almost constant attention. The narcissistic personality, however, usually functions at a higher level. He exhibits an inflated sense of self-importance (sometimes camouflaging desperate insecurity), displays disdain for others, and lacks even a semblance of empathy. In contrast, the borderline has a lower self-esteem and is highly dependent on others' reassurance. The borderline desperately clings to others and is usually more sensitive to their reaction.

Like the borderline, the antisocial personality exhibits impulsivity, poor tolerance of frustration, and manipulative relationships. The antisocial personality, however, lacks a sense of guilt or conscience; he is more detached and is not purposefully self-destructive.

The histrionic personality shares with the borderline tendencies of attention-seeking, manipulativeness, and shifting emotions. The histrionic, however, usually develops more stable roles and relationships. He is usually more flamboyant in speech and manner, and emotional reactions are exaggerated. Physical attractiveness is the histrionic's primary concern. One study compared psychological and social functioning in patients with BPD, schizotypal, obsessive-compulsive, or avoidant personality disorders and patients with major depression. Patients with borderline and schizotypal personality disorders were significantly more functionally impaired than those with the other personality disorders and those with major depression.
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BPD and chemical abuse are frequently associated. Nearly one-third of those with a lifetime diagnosis of substance abuse also fulfill criteria for BPD. And over 50 percent of BPD inpatients also abuse drugs or alcohol.
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Alcohol or drugs might reflect self-punishing, angry, or impulsive behaviors, a craving for excitement, or a mechanism of coping with loneliness. Drug dependency may be a substitute for nurturing social relationships, a familiar, comforting way to stabilize or self-medicate fluctuating moods, or a way to establish some sense of belonging or self-identification. These possible explanations for the appeal of chemical abuse are also some of the defining criteria for BPD.

Anorexia nervosa and bulimia have become major health problems in this country, especially among young women. Eating disorders are fueled by a fundamental distaste for one's own body and a general disapproval of one's identity. The anorexic sees herself in absolute black or white extremes—as either obese (which she always feels) or thin (which she feels she never completely achieves). Since she constantly feels out of control, she impulsively utilizes starvation or binging and purging to maintain an illusion of self-control. The similarity of this pattern to the borderline pattern has led many mental health professionals to infer a strong connection between the two. Indeed, many studies confirm the high prevalence of personality disorders in those with eating disorders and, conversely, the frequent co-occurrence of personality disorders in those with any eating disorder.
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Certain compulsive or destructive behaviors may reflect borderline patterns. For example, a compulsive gambler will continue to gamble despite a shortage of funds. He may be seeking a thrill from a world that habitually leaves him bored, restless, and numb. Or the gambling may be an expression of impulsive self-punishment. Shoplifters often steal items they do not need. Fifty percent of bulimics exhibit kleptomania, drug use, or promiscuity.
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When these behaviors are governed by compulsion, they may represent a need to feel or a need to self-inflict pain.

Promiscuity often reflects a need for constant love and attention from others, in order to hold on to positive feelings about oneself. The borderline typically lacks consistent, positive self-regard and requires continuous reassurance. A borderline woman, lacking in self-esteem, may perceive her physical attractiveness as her only asset and may require confirmation of her worth by engaging in frequent sexual encounters. Such involvements avoid the pain of being alone and create artificial relationships she can totally control. Feeling desired can instill a sense of identity. When self-punishment becomes a prominent part of the psychodynamics, humiliation and masochistic perversions may enter the relationships. From this perspective, it is logical to speculate that many prostitutes and pornographic actors and models may be borderline.

Difficulties with relationships may result in private, ritualistic thinking and behaviors, often expressed as obsessions or compulsion. A borderline may develop specific phobias as he employs magical thinking to deal with fears; sexual perversions may evolve as a mechanism to approach intimacy.

Because borderlines yearn for direction and acceptance, they may be attracted to strong leaders of disciplined groups. The cult can be very enticing since it provides instant and unconditional acceptance, automatic intimacy, and a paternalistic leader who will be readily idealized. The borderline can be very vulnerable to such a black-and-white worldview in which “evil” is personified by the outside world and “good” is encompassed within the cult group.

As many as 70 percent of BPD patients attempt suicide, and the rate of completed suicide approaches 10 percent, almost a thousand times the rate seen in the general population. In the high-risk group of adolescents and young adults (ages fifteen to twenty-nine), BPD was diagnosed in a third of suicide cases. Hopelessness, impulsive aggressiveness, major depression, concurrent drug use, and a history of childhood abuse increase the risk. Although anxiety symptoms are often associated with suicide in other illnesses, borderlines who exhibit significant anxiousness are actually less likely to commit suicide.
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The current official definition of borderline pathology is contained in the DSM-IV-TR diagnostic criteria of Borderline Personality Disorder.
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This designation emphasizes descriptive, observable behavior.

The diagnosis of BPD is confirmed when at least five of the following nine criteria are present.

Just as an infant cannot distinguish between the temporary absence of her mother and her “extinction,” the borderline often experiences temporary aloneness as perpetual isolation. As a result, the borderline becomes severely depressed over the real or perceived abandonment by significant others and then enraged at the world (or whoever is handy) for depriving her of this basic fulfillment.

Fears of abandonment in the borderline can even be measured in the brain. One study utilized PET scanning to demonstrate that women with BPD experienced alterations of blood flow in certain areas of the brain when exposed to memories of abandonment.
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Particularly when they are alone, borderlines may lose the sensation of existing, of feeling real. Rather than embracing Descartes' “I think, therefore I am” principle of existence, they live by a philosophy closer to “Others act upon me, therefore I am.”

The theologian Paul Tillich wrote that “loneliness can be conquered only by those who can bear solitude.” Because the borderline finds solitude so difficult to tolerate, she is trapped in a relentless metaphysical loneliness from which the only relief comes in the form of the physical presence of others. So she will often rush to singles bars or other crowded haunts, often with disappointing—or even violent—results.

In
Marilyn: An Untold Story
, Norman Rosten recalled Marilyn Monroe's hatred of being alone. Without people constantly around her, she would fall into a void, “endless and terrifying.”
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For most of us, solitude is longed for, cherished, a rare opportunity to reflect on memories and matters important to our well-being—a chance to get back in touch with ourselves, to rediscover who we are: “The walls of an empty room are mirrors that double and redouble our sense of ourselves,” the late John Updike wrote in
The Centaur.

But the borderline, with only the weakest sense of self, looks back at only vacant reflections. Solitude recapitulates the panic that the borderline experienced as a child when faced with the prospect of abandonment by parents: Who will take care of me? The pain of loneliness can only be relieved by the rescue of a fantasized lover, as expressed in the lyrics of countless love songs.

The borderline's unstable relationships are directly related to his intolerance of separation and fear of intimacy. The borderline is typically dependent, clinging, and idealizing until the lover, spouse, or friend repels or frustrates these needs with some sort of rejection or indifference, then the borderline caroms to the other extreme—devaluation, resistance to intimacy, and outright avoidance. A continual tug-of-war develops between the wish to merge and be taken care of, on the one hand, and the fear of engulfment, on the other. For the borderline, engulfment means the obliteration of separate identity, the loss of autonomy, and a feeling of nonexistence. The borderline vacillates between a desire for closeness to relieve the emptiness and boredom, and fear of intimacy, which is perceived as the thief of self-confidence and independence.

In relationships, these internal feelings are dramatically translated into intense, shifting, manipulative couplings. The borderline often makes unrealistic demands of others, appearing to observers as spoiled. Manipulativeness is manifested through physical complaints and hypochondriasis, expressions of weakness and helplessness, provocative actions, and masochistic behaviors. Suicidal threats or gestures are often used to obtain attention and rescue. The borderline may use seduction as a manipulative strategy, even with someone known to be inappropriate and inaccessible, such as a therapist or minister.

Though very sensitive to others, the borderline lacks true empathy. He may be dismayed to encounter an acquaintance, such as teacher, coworker, or therapist, outside of his usual place of business because it is difficult to conceive of that person as having a separate life. Furthermore, he may not understand or be extremely jealous of his therapist's separate life, or even of other patients he may encounter.

The borderline lacks “object constancy,” the ability to understand others as complex human beings who nonetheless can relate in consistent ways. The borderline experiences another on the basis of his most recent encounter, rather than on a broader-based, consistent series of interactions. Therefore, a constant, predictable perception of another person never emerges—the borderline, as if afflicted with a kind of targeted amnesia, continues to respond to that person as someone new on each occasion.

Because of the borderline's inability to see the big picture, to learn from previous mistakes, and to observe patterns in his own behavior, he often repeats destructive relationships. A female borderline, for example, will typically return to her abusive ex-husband, who proceeds to abuse her again; a male borderline frequently couples with similar, inappropriate women with whom he repeats sadomasochistic affiliations. Since the borderline's dependency is often disguised as passion, the spouse persists in the destructive relationship “because I love him.” Later, when the relationship disintegrates, one partner can blame the other's pathology. Thus, as is often heard in the therapist's office, “My first wife was a borderline!”