I Hate You--Don't Leave Me: Third Edition: Understanding the Borderline Personality

by Jerold J. Kreisman

“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!”

(While this seems to detail an example of a behavior / the author does make some questionable decisions throughout book when addressing sexual behaviors in general and within the context of specific gender roles. Definitely some exists overlays in thinking.)

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.”

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.

Indeed, BPD patients consume a greater percentage of mental health services than those with just about any other diagnosis.5,6 Additionally, studies corroborate that about 90 percent of patients with the BPD diagnosis also share at least one other major psychiatric diagnosis.7,8 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 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.

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.

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.

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

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.

The nine criteria may be summarized as follows (each is described in depth in chapter 2): Frantic efforts to avoid real or imagined abandonment. Unstable and intense interpersonal relationships. Lack of clear sense of identity. Impulsiveness in potentially self-damaging behaviors, such as substance abuse, sex, shoplifting, reckless driving, binge eating. Recurrent suicidal threats or gestures, or self-mutilating behaviors. Severe mood shifts and extreme reactivity to situational stresses. Chronic feelings of emptiness. Frequent and inappropriate displays of anger. Transient, stress-related feelings of unreality or paranoia.

Mood instability (criteria 1, 6, 7, and 8).

Impulsivity and dangerous uncontrolled behavior (criteria 4 and 5). Interpersonal psychopathology (criteria 2 and 3). Distortions of thought and perception (criterion 9).

For someone with BPD, much of life is a relentless emotional roller coaster. For those living with, loving, or treating someone with BPD, the trip can seem just as wild, hopeless, and frustrating.

millions of other BPD patients are provoked to rage uncontrollably against the people they love most.

They feel helpless and empty, with an identity splintered by severe emo...

Mood changes come swiftly, explosively, carrying the borderline individual from the heights of joy to the depths of depression. Filled with anger one hour, calm the next, he often has little inkling about why he was driven to such wrath. Afterward, the inability to unders...

A borderline individual suffers a kind of “emotional hemophilia”; she lacks the clotting mechanism needed to moderate her spurts of feeling. Prick a passi...

Sustained periods of contentment are foreign to the BPD sufferer. Chronic emptiness depletes him until he is desperate to do anything to escape. In the grip of these lows, he is prone to a myriad of impulsive, self-destructive acts—drug and alcohol binges, eating marathons, anorexic fasts, bulimic purges, gambling forays, shopping sprees, sexual promiscuity, and self-mutilation. He ...

Central to the borderline syndrome is the lack of a core sense of identity. When describing themselves, BPD people typically paint a confused or contradictory self-portrait, in contrast to other patients who generally have a much clearer sense of who they are. To overcome their indistinct and mostly negative self-image, borderline individuals, like actors, are constantly searching for “good roles,” complete “characters” they can inhabit to fill their identity void. So they often adapt like chameleons to the environment, situation, or companions of the moment, much

The lure of ecstatic experiences, whether attained through sex, drugs, or other means, is sometimes overwhelming for the BPD sufferer. In ecstasy, he can return to a primal world where the self and the external world merge—a form of second infancy. During periods of intense loneliness and emptiness, he will go on drug binges, bouts with alcohol, or sexual escapades (with one or several partners), sometimes lasting days at a time. It is as if when the struggle to find an identity becomes intolerable, the solution is either to lose one’s identity altogether or to achieve a semblance of self through pain or numbness.

A borderline childhood is frequently a desolate battlefield, scarred with the debris of indifferent, rejecting, or absent parents, emotional deprivation, and chronic abuse. Most studies have found a history of severe psychological, physical, or sexual abuse in many borderline patients.

Indeed, a history of mistreatment, witness to violence, neglect, or invalidation of experience by parents or primary caregivers distinguishes borderline patients from other psychiatric patients.23,24 Such patients are more vulnerable to other medical illnesses and are more likely to exhibit alterations in hormonal, inflammatory,

These unstable relationships carry over into adolescence and adulthood, where romantic attachments are highly charged and usually short-lived. The borderline individual will frantically pursue a partner one day and send him packing the next.

The world of a borderline adult, like that of a child, is split into heroes and villains.

At any particular moment, one is either “good” or “evil”; there is no in-between, no gray area. Nuances and shadings are grasped with great difficulty, if at all. Lovers and mates, mothers and fathers, siblings, friends, and psychotherapists may be idolized one day, totally devalued and dismissed the next.

When the idealized person finally disappoints (as we all do, sooner or later), the borderline person must drastically restructure her strict, inflexible conceptualization. Either the idol is banished to the dungeon or she banishes herself in order to preserve the “all-good” image of the other person.

Most individuals can experience ambivalence and perceive two contradictory feeling states at one time; those with BPD characteristically shift back and forth, entirely unaware of one emotional state while immersed in another.

Splitting creates an escape hatch from anxiety: the borderline person typically experiences a close friend or relation (call him “Joe”) as two separate people at different times. One day, she can admire “Good Joe” without reservation, perceiving him as completely good; his negative qualities do not exist; they have been purged and attributed

to “Bad Joe.” Other days, she can guiltlessly and totally despise “Bad Joe” and rage at his evil without self-reproach—for now his positive traits ...

Despite feeling continually victimized by others, a borderline individual desperately seeks out new relationships; for solitude, even temporary aloneness, is more intolerable than mistreatment. To escape the loneliness, the person with BPD will flee to singles bars, hookup websites, the arms of recent pickups, somewhere—anywhere—to meet someone who might save her from the torment of her own thoughts. She is constantly searching for Mr. Goodbar or Ms. Tinder.

In a sense, someone with BPD 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 people with BPD may 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 their 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.

The helping professions—medicine, nursing, clergy, counseling—also attract many with BPD, who strive to achieve the power or control that elude them in social relationships. Perhaps more important, in these roles they can provide the care for others—and receive the recognition from others—that they yearn for in their own lives.

Spouses of patients with BPD also show increased healthcare costs and costs of lost productivity.30

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.32,33,34,35 Many borderline patients improve without consistent treatment, although continued therapy hastens improvement.36

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

“The most difficult part of being a borderline personality has been the emptiness, the loneliness, and the intensity of feelings,” she says today. “The extreme behaviors keep me so confused. At times I don’t know what I’m feeling or who I am.”

Carrie, at forty-six, has had to learn that an entire set of previous behaviors are no longer acceptable. “I don’t have the option of cutting myself or overdosing or being hospitalized anymore. I vowed I would live in and deal with the real world, but I’ll tell you, it’s a frightening place. I’m not sure yet whether I can do it or whether I want to do it.”

One widely accepted model suggests that individual personality is actually a combination of temperament (inherited personal characteristics, such as impatience, vulnerability to addiction, etc.) and character (developmental values emerging from environment and life experiences)—in other words, a “nature-nurture” mix. Temperament characteristics may be correlated with genetic and biological markers, develop early in life, and are perceived as instincts or habits. Character emerges more slowly into adulthood, shaped by encounters in the world. Through the lens of this model, BPD may be viewed as the collage resulting from the collision of genes and environment.

For example, BPD may be submerged in the wake of a more prominent and severe depression. After resolution of the depression with antidepressant medications, borderline characteristics may surface and only then be recognized as the underlying character structure requiring further treatment. Second, BPD may be closely linked and perhaps even contribute to the development of another disorder. For example, the impulsivity, self-destructiveness, interpersonal difficulties, deflated self-image, and moodiness often exhibited by patients with substance abuse or eating disorders may be more reflective of BPD than the primary disorder. Although

Though some have argued that BPD is a form of bipolar disorder, clinical, genetic, and imaging studies distinguish the illnesses, and the clinical differences between these syndromes are dramatic. For those afflicted with bipolar disorder, episodes of depression or mania represent radical departures in functioning. Mood changes last from days to weeks. Between mood swings, these individuals maintain relatively normal lives and can usually be treated effectively with medications.

When exhibiting hyperactive, self-destructive, or suicidal behaviors, or experiencing wide and rapid mood swings, the borderline individual may appear bipolar. However, BPD mood variations are more transient (lasting hours rather than days or weeks), more unstable, and more often reactive to environmental stimuli.5,6 The criteria that most effectively distinguish BPD from bipolar disorder are abandonment fears and identity disturbance.7

Some prospective studies have noted that children diagnosed with ADHD frequently develop a personality disorder, especially BPD, as they get older. A Swedish study indicated that individuals with a diagnosis of ADHD were almost twenty times more likely to also have a BPD diagnosis than those not diagnosed with ADHD.11 Retrospective researchers have determined that adults with the diagnosis of BPD often fit a childhood diagnosis of ADHD.12,13,14

Interestingly, one study demonstrated that treatment of ADHD symptoms also ameliorated BPD symptoms in patients diagnosed with both disorders.

The borderline individual may focus on his physical ills, complaining loudly and dramatically to medical personnel and acquaintances, in order to maintain dependency relationships with them. He may be considered merely a hypochondriac, while the underlying understanding of his problems is completely ignored. Somatization disorder is a condition defined by the patient’s multiple physical complaints (including pain, gastric, neurological, and

sexual symptoms), unexplained by any known medical condition. In hypochondriasis, the patient is convinced he has a terrible disease despite a medical evaluation that reveals no evidence of one.20

BPD and Compulsive Behaviors 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.

Promiscuity often reflects a need for constant love and attention from others, in order to hold on to positive feelings about oneself. The borderline individual 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.

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

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.