Listening to Borderline Personality Disorder
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The borderline riddle may offer the key to your own personal insight.
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Borderline personality disorder. At first blush, borderline personality disorder appears very much like bipolar disorder, and the DSM symptom list does little to disabuse us of that notion. Thus (symptoms 4-7): impulsivity, recurrent suicidal behavior, affective instability, chronic feelings of emptiness.
John Gunderson of Harvard, in the July 2006 American Journal of Psychiatry, notes that misdiagnosing patients with bipolar, especially bipolar II, is the norm. Periods of depression and irritability are rarely instructive, he says. Neither are sustained periods of elation. What we are really looking for, he informs us, is evidence of a stress connection. Thus:
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Repeated angry outbursts, suicide attempts, or acts of deliberate self-harm that are reactive to interpersonal stress and reflect extreme rejection sensitivity are axiomatic of borderline personality disorder. In the presence of these symptoms, the diagnosis of a bipolar disorder is unlikely or secondary.
Borderline Primitive Defenses
In 1975, the legendary psychoanalyst Otto Kernberg of Columbia University theorized that "borderline personality organization" results from the child's inability to integrate positive and negative into a coherent whole. This leads to the incorporation of primitive defense mechanisms that carry on through adulthood. The best-known involves "splitting," in which people are perceived as either all good or all bad, nothing in between.
All-good or all-bad status has a way of changing like the weather in New England, only with far less predictability. Mother Teresa today, Whore of Babylon tomorrow. No in-between. In DSM-speak, we see "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation."
Throw in DSM fear of abandonment, identity disturbance, inappropriate anger, and stress-induced paranoia, and a picture emerges of an extremely fragile individual negotiating a frightening and unpredictable world, at a loss how to respond. As Marsha Linehan of the University of Washington and founder of dialectical-behavioral therapy noted in 1993, "borderline patients are the psychological equivalent of a third-degree burn patient."
Inside the Borderline Blast Zone
Those who live within the blast zone of someone with borderline, however, tend to view themselves as the ones with the third-degree burns. Typically, they describe themselves as constantly having to walk on eggshells. In my own experience, these highly challenging close encounters amount to being forced to dismantle a ticking bomb with seconds on the clock. Do we yank the blue wire or the green one?
Can we calm down an explosive situation or do we duck for cover?
Psychiatrists and therapists tend to base their diagnostic assessments on what their patients tell them in the course of a cursory examination. But family members and others on the scene day in and day out may have a totally different perspective. The queries I typically receive from distressed loved ones describe sustained periods of putting up with the worst kind of emotional (and sometimes physical) abuse and outrageous behavior.
Is this bipolar? they ask. I suspect they are hoping I will say yes. To these individuals, bipolar (very incorrectly) implies a quick pharmaceutical fix. With borderline, although the prognosis may be favorable, there is no magic pill to the rescue.
In the closing of the movie "Girl Interrupted," based on Susanna Kaysen's book of the same name, we hear in the main character's voice-over: "Crazy isn't being broken or swallowing a dark secret. It's you or me amplified."
Think of Marilyn Monroe. Her larger-than-life personality combined with her personal insecurities has fed speculation that she may have been dealing with borderline. Likewise, a strong case can be made that she was living with bipolar. Either way, both diagnoses seem to fit. Certainly, Marilyn lit up the world.
But there is also the dark side of borderline to contend with, leaving victims dazed and shell-shocked and violated:
"You are not a clinician!" screeched a message in my Wikipedia account "Kindly desist from adding content that serious professionals would find suspect, at best...unsupportable nonsense, at least."
(For the record, serious professionals presented me with a prestigious award and endorsed my book, Living Well with Depression and Bipolar Disorder.)
Other messages from the same individual informed me that I was no longer allowed to contribute to Wikipedia and worse. Plus hate speech on the public forums, plus he went in and altered my profile, pretending to be me, in highly unflattering terms.
Sick stuff, really sick.
I happened to revisit this account for the first time in more than five years as I was working on this series of articles (late May, 2011), and even after all this time my psyche reacted as if someone had just pulled the pin on a hand grenade. Obviously, I don't want to use the B-word every time I have a bad encounter, but the behavior I am describing is very consistent with the diagnosis and with the stories that survivors of borderline abuse report.
Books such as "Walking on Eggshells" by Paul Mason and Randi Kreger provide excellent pointers on how to protect yourself from borderline meltdowns. For those of us with mood disorders, self-protection is far more urgent. The pile of abuse from the sicko on Wikipedia kickstarted my racing thoughts and messed up my sleep for days on end, putting me at grave risk of spinning into an episode.
In the situation I describe in the opening to the first article in this series on borderline, after one poison pen email too many, the invisible floor that was holding up my emotions gave way, and my mood dropped like a rock. I spent one miserable month fighting off a bear of a depression.
Listening to Borderline
In 2006, the year I first started seriously investigating borderline, NAMI expanded its list of "priority populations" to include those with borderline personality disorder. As a result, their annual convention had on offer an ask the doctors session devoted to this illness, where I had a chance to listen to individuals speaking openly in an environment where they felt safe.
On the panel was a patient – we'll call her Anne – who presented a human face to the condition. Late 30s-early 40s, very smart, very articulate, very personable, with a degree in creative writing. Unfortunately, she told us, the best job she can get is answering phones, and she feels herself lucky. Her illness cannot take the demands of something more challenging, more stressful, that would place her in pressure cooker situations amongst people. When she loses it, she admits, you don't really want to be around her.
As opposed to walking on eggshells, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, she related, and the ground beneath her could collapse any second.
"It's like demons possess me," she on to say. Something inside of yourself so overwhelms you that you want to change it instantly. Such as slitting your wrists, impulsive sex, alcohol, and acting out. She described individuals with borderline as spontaneous and lively and loving until they get hurt. Then they screw up and fall apart. The irony, she said, is people with this disorder want to help so much, but the problem is they have trouble relating to people.
Anne emphasized that people with borderline can change (another speaker referred to the illness as "the good prognosis diagnosis"), and she concluded with reference to her favorite bumper sticker, "Don't believe everything you think."
Facing Up to Borderline
I do not want wish to leave the impression that I am describing a THEM vs US situation. We all have personality issues we must deal with, and in my observations these often pose a greater problem in our recovery than our actual illness. Accordingly, I urge individuals to study the personality disorders as if each one applied to them.
Psychiatry and its allied disciplines will never figure out personality to everyone's satisfaction (the DSM-5 is working on it), and it would be a sad indictment on our uniqueness as individuals if they ever did. But you can employ these various diagnostic rough guides to connect your own dots, fill in your own blanks, and get to know yourself better.
In the meantime, whether you meet the threshold for a borderline diagnosis or not, dialectical-behavioral therapy - a form of cognitive therapy directed at reconciling apparent opposites - is extremely useful, with a very high success rate. Meds may help in the sense of slowing down an over-reactive brain, but they cannot turn destructive behavioral traits into constructive ones. The best biological weapon in this case is using the brain to change the brain.
DBT lays heavy stress on the practice of mindfulness - the mind watching the mind - which can be a tall order when your brain won't cooperate, but even a minor improvement is a major achievement.
We think of personal change as drawn-out and incremental, but quantum breakthroughs are fairly common, of entire neural networks realigning in response to new habits and eye-opening realizations. Never give up on yourself ...
Previous articles:
Is Borderline Personality Disorder Real? * Borderline Personality Disorder Gains Respect
First published July 14, 2006, expanded into three articles May 29, 2011
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