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

by Jerold J. Kreisman

As a result, she 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.

This “borderline empathy paradox” reflects the theory that patients with BPD experience heightened sensitivity for social cues but are impaired in integrating this interpersonal information.44 It has also been observed that borderline patients empathize more with people in distressful or negative situations than with people in positive social situations. This may reflect their greater familiarity with negative emotions and situations. One study examined the effect of intranasal oxytocin on empathy in borderline women.

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

Because of the borderline individual’s inability to see the big picture, to learn from previous mistakes, and to observe patterns

often leads to partners with complementary pathology: both lack insight into their mutual destructiveness.

it.” The borderline self cannot seem to gain enough independence to be dependent in healthy, rather than desperate, ways. True sharing is sacrificed to a demanding dependency and a desperate need to merge with another person in order to complete one’s own identity, as kind of Siamese twins of the soul. And when the relationship is threatened, the borderline person may feel like a piece of herself is ripped away. “You

The borderline individual does not accept her own intelligence, attractiveness, or sensitivity as constant traits, but rather as comparative qualities to be continually re-earned and judged against others’. She may view herself as intelligent, for example, based solely on the results of a just-administered IQ test.

As explored in chapter 3, the pre-borderline child often grows up feeling inauthentic due to various environmental circumstances—suffering physical or sexual abuse or being forced to adopt an adult’s role while still a child or to parent his own sick parent. At the other extreme, he may be discouraged from maturing and separating, and may be trapped in a dependent child’s role, well past an appropriate time for separation. In all of these situations, the emerging borderline identity never develops a separate sense of self but continues to “fake” a role that is prescribed by someone else.

Borderline behaviors may be sudden and contradictory, since they result from strong momentary feelings—perceptions that represent isolated, unconnected snapshots of experience. The

Because historical patterns, consistency, and predictability are unavailable to the borderline experience, similar impulsive mistakes are repeated again and again. Christopher Nolan’s 2000 film Memento presents metaphorically what the borderline individual faces on a regular basis.

Often, the frequent threats or halfhearted suicide attempts are not a wish to die but rather a way to communicate pain and a plea for others to intervene. Unfortunately, when habitually repeated, these suicidal gestures often lead to just the opposite scenario—others get fed up and stop responding, which may result in progressively more serious attempts.

Though many people get tattoos for decorative reasons, on a societal level the increasing fascination with tattoos and piercings over the past three decades may be less a fashion trend than a reflection of borderline tendencies in society (see chapter 4). Sometimes the desperate need to fit in may stimulate a person with BPD (usually an adolescent) to “copycat” cutting or to carve words or names in her skin.

The borderline individual undergoes abrupt and extreme mood shifts, lasting for short periods—usually hours. His base mood is not usually calm and controlled, but more often either hyperactive and irrepressible or pessimistic, cynical, and depressed.

Justin was rushed to the emergency room by his girlfriend after increasing expressions of desperation and intention to overdose. On admission to the psychiatric

unit, he tearfully expressed his hopelessness and persistent wishes to die to the nurse, sobbing uncontrollably. Yet literally minutes later he was spied laughing and joking with his new roommate.

Along with affective instability, anger is a persistent symptom of BPD over time.56 Outbursts of rage are as unpredictable as they are frightening. Violent scenes are disproportionate to the frustrations that trigger them.

The rage, so intense and so near the surface, is often directed at those close to the BPD person—spouse, children, parents. Borderline anger may represent a cry for help, a testing of devotion, or a fear of intimacy—whatever

The rage often carries over to the therapeutic setting, where psychiatrists and other mental health professionals become the target. Carrie, for example, often raged against her therapist, constantly looking for ways to test his commitment to staying with her in therapy. At times she would storm out of her therapist’s office and command the secretary to cancel her future appointments.

The most common psychotic experiences for BPD patients involve feelings of unreality and paranoid delusions. Unreality feelings involve dissociation from usual perceptions. The individual or those around her feel unreal. Some experience a kind of internal splitting, in which they feel different aspects of their personality emerge in different situations. Distorted perceptions can involve any of the five senses.

And yet, to the outside world, the presentation of psychosis in BPD may be indistinguishable, in the acute form, from the psychotic experiences of these other illnesses. The main difference is duration. Within hours or days, the breaks with reality may disappear, as the borderline patient recalibrates to usual functioning, unlike other forms of psychosis.

Family studies suggest that first-degree relatives of borderline patients are several times more likely to show signs of a personality disorder, especially BPD, than the general public. These close family members are also significantly more likely to exhibit mood, impulse, and substance abuse disorders. In family studies focusing on components of the four major sectors that define BPD (mood, interpersonal, behavioral, cognitive), a single genetic pathway accounted for convergence of these symptoms in family

One study found that a family member of someone with BPD is almost four times more likely to develop BPD than a nonrelative.4 Another study of twins examining all nine BPD criteria also concluded that most genetic effects on BPD criteria derive from one heritable general BPD factor. In this research, impulsivity levels in BPD patients appeared to be more highly heritable. In contrast, interpersonal and self-image features were less connected among family members, suggesting these symptoms were more likely influenced by life experiences and were less genetically determined.5 Some

In BPD, frequent abuse of food, alcohol, and other drugs—typically interpreted as self-destructive behavior—may also be seen as an attempt to self-medicate inner emotional turmoil. Borderline patients frequently report the calming effects of self-mutilation; rather than feeling pain, they experience soothing relief or distraction from internal psychological pain.

In many cases the broken parent-child relationship takes the more severe form of early parental loss or prolonged traumatic separation, or both. As with Dixie, many borderline children have an absent or psychologically disturbed father. Primary mother figures (who may sometimes be the father) tend to be erratic and depressed and have significant psychopathology themselves, often BPD. The borderline family background is frequently marked by incest, violence, and/or alcoholism. Many cases show an ongoing hostile or combative relationship between mother and pre-borderline child.

Often, entire families adopt a borderline system of interaction, with the family members’ undifferentiated identities alternately merging with and separating from one another. Melanie, the adolescent daughter in one such family, closely identified with her chronically depressed mother, who felt abandoned by her philandering husband. With her husband often away from home and her other children much younger, the mother latched on to her teenage daughter, relating intimate details of the unhappy marriage and invading the teenager’s privacy with intrusive questions about her friends and activities.

treatment of the entire family (see chapter 7). Family therapy interventions may be focused on education about BPD and skills training for family and others who care deeply. There are three primary family scenarios that can be addressed in helping the BPD person and loved ones: (1) caring for the BPD person and family of origin; (2) caring for the BPD person and his or her new, adult family; (3) helping the BPD person be an effective parent.22 In some cases an individual therapy for the borderline patient is best directed toward distancing or separating from an unremittingly pathological family system.

Major traumas—parental loss, neglect, rejection, physical or sexual abuse—during the early years of development can increase the probability of BPD in adolescence and adulthood. Indeed, case histories of borderline patients are typically desolate battlefields, scarred by broken homes, chronic abuse, and emotional deprivation.

Not all children who are traumatized or abused become borderline adults, of course; nor do all borderline adults have a history of trauma or abuse.

Why do some people develop BPD in spite of an apparently healthy upbringing?

Though no evidence supports a specific BPD gene, humans may inherit chromosomal vulnerabilities that are later expressed as a particular illness, depending on a variety of contributing factors—childhood frustrations and traumas, specific stress events in life, healthy nutrition, exposure to environmental changes or toxins, access to health care, and so

As many persons with BPD learn that they must reject the either-or, black-or-white ways of thinking, researchers are beginning to appreciate that the most likely model for BPD (and for most medical and psychiatric illnesses) recognizes multiple contributing factors—nature and nurture—working and interacting simultaneously. Borderline personality disorder is a complex tapestry, richly embroidered with innumerable intersecting threads.

Though social factors may not be direct causes of BPD (or other forms of mental illness), they are at the very least important indirect influences. Social factors interact with BPD in several ways and cannot be overlooked.

In today’s world of frequent moves, intimate lasting personal relationships become difficult or even impossible to achieve, and deep-seated loneliness, self-absorption, emptiness, anxiety, depression, and loss of self-esteem ensue.

The borderline syndrome represents a pathological response to these stresses. Without outside sources of stability and validation of worthiness, borderline symptoms of black-and-white thinking, self-destructiveness, extreme mood changes, impulsivity, tumultuous relationships, an impaired sense of identity, and anger become understandable reactions to our culture’s tensions. Borderline traits, which may be present to some extent in many people, are being elicited—perhaps even bred—on a wide scale by the prevailing social conditions.

Contemporary social forces implore us to embrace a mythical polarity—black or white, right or wrong, good or bad, guilty or innocent—relying on our nostalgia for simpler times, for our own childhoods.

Empirical studies with adolescents and children consistently show “awareness of the danger, hopelessness about surviving, a shortened time perspective, and pessimism about being able to reach life goals. Suicide is mentioned again and again as a strategy for dealing with the threat.”5 Other studies have found that the threat of world catastrophe rushes children to a kind of “early adulthood,” similar to the type witnessed in pre-borderline children (like Lisa) who are forced to take control of families that are out of control due to BPD, alcoholism, and other mental disorders.

A typical scenario for modern social relationships is a pattern of overlapping lovers, sometimes referred to as shingling—establishing a new romance before severing a current one. BPD exemplifies this constant need for partnership: As she climbs the jungle gym of relationships, she cannot let go of the lower bar until she has firmly grasped the next one. Typically, she will not leave her current abusive spouse until a new “white knight” is at least visible on the horizon.

In parallel with the social turmoil, for gay, lesbian, or transgender people the personal decision to “come out of the closet” is usually ridden with anxiety and the potential of severe social and/or family repercussions. Yet the social context has changed. According to recent surveys, 7 percent of millennials self-identify as gay, as opposed to 3.5 percent in 2011.15

Characteristics of physically abused preschool-age children include inhibition, depression, attachment difficulties, behavior problems (such as hyperactivity and severe tantrums), poor impulse control, aggressiveness, and peer-relation problems. “Violence begets violence,” said John Lennon, and this is particularly true in the case of battered children.

The incidence of abuse or neglect among borderline patients is high enough to be a factor that separates BPD from other personality disorders. Verbal or psychological abuse is the most common form, followed by physical and then sexual abuse. Physical and sexual abuse may be more dramatic in nature, but the emotionally abused child can suffer total loss of self-esteem.

Unavailability/Neglect. Psychologically absent parents show little interest in the child’s development and provide no affection in times of need.

From what we understand of the roots of BPD (see chapter 3), abuse, neglect, or prolonged separations early in childhood can greatly disrupt the developing infant’s establishment of trust. Self-esteem and autonomy are crippled. The abilities to cope with separation and to form identity do not proceed normally.

Studies on the effects of divorce typically report profound upset, neediness, regression, and acute separation anxiety related to fears of abandonment in children of preschool age.28 A significant number are found to be depressed29 or antisocial in later stages of childhood.30 Indeed, teens living in single-parent families are not only more likely to commit suicide but also more likely to suffer from psychological disorders,

In many situations of parental separation, the child becomes the pawn in a destructive battle between his parents.

A person with BPD shifts her personality like a rotating kaleidoscope, rearranging the fragmented glass of her being into different formations—each collage different, yet each, her. Like a chameleon, she transforms herself into any shape that she imagines will please the viewer.

Dealing with borderline behavior can be frustrating for everyone in regular contact with BPD victims because, as we have seen, explosions of anger, rapid mood swings, suspiciousness, impulsive actions, unpredictable

During stressful times, communication with a person with BPD is hindered by his impenetrable, chaotic internal force field, characterized by three major feeling states: terrifying aloneness, feeling misunderstood, and overwhelming helplessness.

formalized therapy. Unlike standard treatment programs directed at durable behavioral changes, SET-UP was designed to confront acute situational occurrences, to ease communication, and to avoid escalation during potential conflicts. Nevertheless, the goals of SET-UP, utilized by nonprofessionals, are consistent with those of formalized programs conducted by clinicians.

SET—Support, Empathy, Truth—is a three-part system of communication (see Figure 5-1). During confrontations of destructive behavior, important decision-making sessions, or other crises, interactions with the borderline individual should invoke all three elements in balanced proportion.

The S stage of SET, Support, invokes a personal “I” statement of concern. “I am sincerely worried about how you are feeling,” “I’m concerned about what you’re dealing with,” and “I want to help” are