Chapter One The World of Borderline Personality Disorder Everything looked and sounded unreal. Nothing was what it is. That's what I wanted-to be alone with myself in another world where truth is untrue and life can hide from itself. -From Long Day's Journey into Night, by Eugene O'Neill Dr. White thought it would all be relatively straightforward. Over the five years he had been treating Jennifer, she'd had few medical problems. Her stomach complaints were probably due to gastritis, he thought, so he treated her with antacids. But when her stomach pains became more intense despite treatment and routine testing proved normal, Dr. White admitted Jennifer to the hospital. After a thorough medical workup, Dr. White inquired about stresses Jennifer might be experiencing at work and home. She readily acknowledged that her job as a personnel manager for a major corporation was very pressured, but as she put it, "Many people have pressure jobs." She also revealed that her home life was more hectic recently. She was trying to cope with her husband's busy legal practice while tending to the responsibilities of being a mother. But she doubted the connection of these factors to her stomach pains. When Dr. White recommended that Jennifer seek psychiatric consultation, she initially resisted. It was only after her discomfort turned into stabs of pain that she reluctantly agreed to see the psychiatrist Dr. Gray. They met a few days later. Appearing childlike and younger than her twenty-eight years, Jennifer lay in bed in a hospital room that had been transformed from an anonymous cubicle into a personalized lair. A stuffed animal sat next to her in bed, and another lay on the nightstand beside several pictures of her husband and son. Get-well cards were meticulously displayed in a line along the windowsill, flanked by flower arrangements. At first Jennifer was very formal, answering all of Dr. Gray's questions with great seriousness. Then she joked about how her job was "driving me to see a shrink." The longer she talked, the sadder she looked. Her voice became less domineering and more childlike. She told him how a job promotion was exacting more demands-new responsibilities that were making her feel insecure. Her five-year-old son was starting school, which was proving to be a difficult separation for both of them. Conflicts with Allan, her husband, were increasing. She described rapid mood swings and trouble sleeping. Her appetite had steadily decreased and she was losing weight. Her concentration, energy, and sex drive had all diminished. Dr. Gray recommended a trial of antidepressant medications, which improved her gastric symptoms and seemed to normalize her sleeping patterns. In a few days she was ready for discharge and agreed to continue outpatient therapy. Over the following weeks, Jennifer talked more about her upbringing. Reared in a small town, she was the daughter of a prominent businessman and his socialite wife. Her father, an elder in the local church, demanded perfection from his daughter and her two older brothers, constantly reminding the children that the community was scrutinizing their behavior. Jennifer's grades, her behavior, even her thoughts were never quite good enough. She feared her father, yet constantly-and unsuccessfully-sought his approval. Her mother remained passive and detached. Her parents evaluated her friends, often deeming them unacceptable. As a result, she had few friends and even fewer dates. Jennifer described her roller-coaster emotions, which seemed to have worsened when she started college. She began drinking for the first time, sometimes to excess. Without warning, she would feel lonely and depressed and then high with happiness and love. On occasion, she would burst out in rage against her friends-fits of anger that she had somehow managed to suppress as a child. It was at about this time that she also began to appreciate the attention of men, something she had previously always avoided. Though she enjoyed being desired, she always felt she was "fooling" or tricking them somehow. After she began dating a man, she would sabotage the relationship by stirring up conflict. She met Allan as he was completing his law studies. He pursued her relentlessly and refused to be driven away when she tried to back off. He liked to choose her clothes and advise her on how to walk, how to talk, and how to eat nutritiously. He insisted she accompany him to the gym where he frequently worked out. "Allan gave me an identity," she explained. He advised her on how to interact with his society partners and clients, when to be aggressive, when to be demure. She developed a cast of "repertoire players"-characters or roles whom she could call to the stage on cue. They married, at Allan's insistence, before the end of her junior year. She quit school and began working as a receptionist, but her employer recognized her intelligence and promoted her to more responsible jobs. At home, however, things began to sour. Allan's career and his interest in bodybuilding caused him to spend more time away from home, which Jennifer hated. Sometimes she would start fights just to keep him home a little longer. Frequently, she would provoke him into hitting her. Afterward she would invite him to make love to her. Jennifer had few friends. She devalued women as gossipy and uninteresting. She hoped that her son Scott's birth, coming two years after her marriage, would provide the comfort she lacked. She felt her son would always love her and always be there for her. But the demands of an infant were overwhelming, and after a while, Jennifer decided to return to work. Despite frequent praise and successes at work, Jennifer continued to feel insecure, that she was "faking it." She became sexually involved with a coworker who was almost forty years her senior. "Usually I'm okay," she told Dr. Gray. "But there's another side that takes over and controls me. I'm a good mother. But my other side makes me a whore; it makes me act crazy!" Jennifer continued to deride herself, particularly when alone; during times of solitude, she would feel abandoned, which she attributed to her own unworthiness. Anxiety would threaten to overwhelm her unless she found some kind of release. Sometimes she'd indulge in eating binges, once consuming an entire bowl of cookie batter. She would spend long hours gazing at pictures of her son and husband, trying to "keep them alive in my brain." Jennifer's physical appearance at her therapy sessions fluctuated dramatically. When coming directly from work, she would dress in a business suit that exuded maturity and sophistication. But on her days off, she showed up in short pants and knee socks, with her hair in braids; at these appointments she acted like a little girl with a high-pitched voice and used a more limited vocabulary. Sometimes she would transform right before Dr. Gray's eyes. She could be insightful and intelligent, working collaboratively toward greater self-understanding, and then become a child, coquettish and seductive, pronouncing herself incapable of functioning in the adult world. She could be charming and ingratiating or manipulative and hostile. She could storm out of one session, vowing never to return, and at the next session cower with the fear that Dr. Gray would refuse to see her again. Jennifer felt like a child clad in the armor of an adult. She was perplexed at the respect she received from other adults; she expected them to see through her disguise at any moment, revealing her to be an empress with no clothes. She needed someone to love and protect her from the world. She desperately sought closeness, but when someone came too close, she ran. Jennifer is afflicted with Borderline Personality Disorder (BPD). She is not alone. Studies estimate that as many as 19 million or more Americans (3 to 6 percent of the population) exhibit primary symptoms of BPD, and many studies suggest this figure is an underestimation. Approximately 10 percent of psychiatric outpatients and 20 percent of inpatients, and between 15 and 25 percent of all patients seeking psychiatric care, are diagnosed with the disorder. It is one of the most common of all of the personality disorders. Yet, despite its prevalence, BPD remains relatively unknown to the general public. Ask the man on the street about anxiety, depression, or alcoholism, and he would probably be able to provide a sketchy, if not technically accurate, description of the illness. Ask him to define Borderline Personality Disorder, and he would probably give you a blank stare. Ask an experienced mental health clinician about the disorder, on the other hand, and you will get a much different response. She will sigh deeply and exclaim that of all her psychiatric patients, borderline patients are the most difficult, the most dreaded, and the most to be avoided-more than those with schizophrenia, more than those suffering from alcoholism or substance abuse, more than any other patient. For decades BPD has been lurking as a kind of "Third World" of mental illness-indistinct, massive, and vaguely threatening. BPD has been underrecognized partly because the diagnosis is still relatively new. For years, "borderline" was used as a catchall category for patients who did not fit more established diagnoses. People described as borderline seemed more ill than neurotic patients (who experience severe anxiety secondary to emotional conflict), yet less ill than psychotic patients (whose detachment from reality makes normal functioning impossible). The disorder also coexists with, and borders on, other mental illnesses: depression, anxiety, bipolar (manic-depressive) disorder, schizophrenia, somatization disorder (hypochondriasis), dissociative identity disorder (multiple personality), attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), alcoholism, drug abuse (including nicotine dependence), eating disorders, phobias, obsessive-compulsive disorder, hysteria, sociopathy, and other personality disorders. Though the term borderline was first coined in the 1930s, the condition was not clearly defined until the 1970s. For years, psychiatrists could not seem to agree on the separate existence of the syndrome, much less on the specific symptoms necessary for diagnosis. But as more and more people began to seek therapy for a unique set of life problems, the parameters of the disorder crystallized. In 1980, the diagnosis of Borderline Personality Disorder was first defined in the American Psychiatric Association's third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the diagnostic "bible" of the psychiatric profession. Since then, several revisions of the DSM have been produced, the most recent being DSM-5, published in 2013. Though various schools within psychiatry still quarrel over the exact nature, causes, and treatment of BPD, the disorder is officially recognized as a major mental health problem in America today. Indeed, BPD patients consume a greater percentage of mental health services than those with just about any other diagnosis. Additionally, studies corroborate that about 90 percent of patients with the BPD diagnosis also share at least one other major psychiatric diagnosis.BPD is also often connected to significant medical diseases, especially in women. These include chronic headaches and other pain, arthritis, and diseases of the cardiovascular, gastrointestinal, urinary, pulmonary, hepatic, immune, and oncological systems.In 2008, the U.S. House of Representatives designated May as Borderline Personality Disorder Awareness Month. And yet, unfortunately, current government-sponsored research on BPD represents only a fraction of the work directed to less common disorders, such as schizophrenia or bipolar disorder. In many ways, the borderline syndrome has been to psychiatry what a virus is to general medicine: an inexact term for a vague but pernicious illness that is frustrating to treat, difficult to define, and impossible for the doctor to explain adequately to his patient. Demographic Borders Who are the borderline people one meets in everyday life? She is Carlotta, a friend since grade school. Over a minor slight, she accuses you of stabbing her in the back and tells you that you were really never her friend at all. Weeks or months later, Carlotta calls back, congenial and blasZ, as if nothing had happened between you. He is Bob, a boss in your office. One day Bob bestows glowing praise for your efforts in a routine assignment; another day, he berates you for an insignificant error. At times he is reserved and distant; other times he is suddenly and uproariously "one of the boys." She is Arlene, your son's girlfriend. One week, she is the picture of preppy; the next, she is the epitome of punk. She breaks up with your son one night, only to return hours later, pledging endless devotion. He is Brett, your next-door neighbor. Unable to come to grips with his collapsing marriage, he denies his wife's obvious unfaithfulness in one breath, and then takes complete blame for it in the next. He clings desperately to his family, caroming from guilt and self-loathing to raging attacks on his wife and children who have so "unfairly" accused him. If the people in these short profiles seem inconsistent, it should not be surprising-inconsistency is the hallmark of BPD. Unable to tolerate paradox, those with borderline personality are walking paradoxes, human catch-22s. Their inconstancy is a major reason why the mental health profession has had such difficulty defining a uniform set of criteria for the illness. If these people seem all too familiar, this also should not be surprising. The chances are good that you have a spouse, relative, close friend, or coworker who has borderline personality. Perhaps you know a little bit about BPD or recognize borderline characteristics within yourself. Though it is difficult to get a firm grasp on the figures, mental health professionals generally agree that the number of borderline individuals in the general population is growing-and at a rapid pace-though some observers claim that it is the therapists' awareness of the disorder that is growing rather than the number of borderline patients. Is borderline personality really a modern-day "plague," or is merely the diagnostic label borderline new? In any event, the disorder has provided new insight into the psychological framework of several related conditions. Numerous studies have linked BPD with anorexia, bulimia, ADHD, drug addiction, and teenage suicide-all of which have increased alarmingly over the last decade. Some studies have uncovered BPD in almost 50 percent of all patients admitted to a facility for an eating disorder. Other studies have found that over 50 percent of substance abusers also fulfill criteria for BPD. Self-destructive tendencies or suicidal gestures are very common among borderline patients-indeed, they are one of the syndrome's defining criteria. As many as 70 percent of BPD patients attempt suicide. The incidence of documented death by suicide is about 8 to 10 percent and even higher for borderline adolescents. A history of previous suicide attempts, a chaotic family life, and a lack of support systems increase the likelihood. The risk multiplies even more among borderline patients who also suffer from depressive or manic-depressive (bipolar) disorders, or from alcoholism or drug abuse. How Doctors Diagnose Psychiatric Disease Before 1980, DSM-I and II described psychiatric illnesses in descriptive terms. However, starting with DSM-III, psychiatric disorders have been defined along structured, categorical paradigms; that is, several symptoms have been proposed to be suggestive of a particular diagnosis, and when a certain number of these criteria are met, the individual is considered to fulfill the categorical requirements for diagnosis. Interestingly, in the four revisions of DSM since 1980, only minor adjustments have been made to the definitional criteria for BPD. As we shall see shortly, nine criteria are associated with BPD, and an individual qualifies for the diagnosis if he exhibits five or more of the nine. Excerpted from I Hate You--Don't Leave Me: Third Edition: Understanding the Borderline Personality by Jerold J. Kreisman, Hal Straus All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
