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

by Jerold J. Kreisman

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

Indeed, a history of mistreatment, witness to violence, or invalidation of experience by parents or primary caregivers distinguishes borderline patients from other psychiatric patients.

Some critics feel that a kind of clinician bias operates with borderline diagnoses: Psychotherapists may perceive problems with identity and impulsivity as more “normal” in men; as a result, they may underdiagnose BPD among males. Where destructive behavior in women may be seen as a result of mood dysfunction, similar behavior in men may be perceived as antisocial. Where women in such predicaments may be directed toward treatment, men may instead be channeled through the criminal justice system where they may elude correct diagnosis forever.

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.

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.

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.

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.

Borderlines lack a constant, core sense of identity, just as they lack a constant, core conceptualization of others. The borderline 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’.

The borderline allows herself no laurels on which to rest. Like Sisyphus, she is doomed to roll the boulder repeatedly up the hill, needing to prove herself over and over again. Self-esteem is only attained through impressing others, so pleasing others becomes critical to loving herself.

As explored in chapter 3, the pre-borderline 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.

Unrealistic attempts at achieving a state of perfection are often part of the borderline pattern. For example, a borderline anorexic might try to maintain a constant low weight and become horrified if it varies as little as one pound, unaware that this expectation is unrealistic. Perceiving themselves as static, rather than in a dynamic state of change, borderlines may view any variation from this inflexible self-image as shattering.

The borderline’s outbursts of rage are as unpredictable as they are frightening. Violent scenes are disproportionate to the frustrations that trigger them. Domestic fracases that may involve chases with butcher knives and thrown dishes are typical of borderline rage. The anger may be sparked by a particular (and often trivial) offense, but underneath the spark lies an arsenal of fear from the threat of disappointment and abandonment.

While digesting this chapter, the astute reader will observe that these symptoms typically interact; they are less like isolated lakes than streams that feed into each other and eventually merge into rivers and then into bays or oceans. They are also interdependent. The deep furrows etched by these floods of emotions inform not only the borderline but also parts of the culture in which he lives.

The available evidence points to no one definitive cause—or even type of cause—of BPD. Rather, a combination of genetic, developmental, neurobiological, and social factors contribute to the development of the illness.

Changes in brain metabolism and morphology (or structure) are also associated with BPD. Borderline patients express hyperactivity in the part of the brain associated with emotionality and impulsivity (limbic areas), and decreased activity in the section that controls rational thought and regulation of emotions (the prefrontal cortex). (Similar imbalances are observed in patients suffering from depression and anxiety.) Additionally, volume changes in these parts of the brain are also associated with BPD and are correlated with these physiological changes.

Either extreme of parental behavior—behavioral over-control and/or emotional under-involvement—can result in the child’s failure to develop a positive, stable sense of self and may lead to a constant, intense need for attachment and chronic fears of abandonment.

Aiding the child in all these tasks are transitional objects—the familiar comforts (teddy bears, dolls, blankets) that represent mother and are carried everywhere by the child to help ease separations. The object’s form, smell, and texture are physical representations of the comforting mother. Transitional objects are one of the first compromises made by the developing child in negotiating the conflict between the need to establish autonomy and the need for dependency. Eventually, in normal development, the transitional object is abandoned when the child is able to internalize a permanent image of a soothing, protective mother figure.

Because they are locked into a continual struggle to achieve object constancy, trust, and a separate identity, adult borderlines continue to rely on transitional objects for soothing. One woman, for example, always carried in her purse a newspaper article that contained quotes from her psychiatrist. When she was under stress, she would take it out, calling it her “security blanket.” Seeing her doctor’s name in print reinforced his existence and his continued interest and concern for her.

As many borderlines 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 is a complex tapestry, richly embroidered with innumerable, intersecting threads.

Like the world of the borderline, ours in many ways is a world of massive contradictions. We presume to believe in peace, yet our streets, movies, television, and sports are filled with aggression and violence. We are a nation virtually founded on the principle of “Help thy neighbor,” yet we have become one of the most politically conservative, self-absorbed, and materialistic societies in the history of humankind. Assertiveness and action are encouraged; reflection and introspection are equated with weakness and incompetency.

A typical scenario for modern social relationships is the “overlapping lover” pattern, commonly called “shingling”—establishing a new romance before severing a current one. The borderline exemplifies this constant need for partnership: As the borderline climbs the jungle gym of relationships, he cannot let go of the lower bar until he has firmly grasped the higher one. Typically, the borderline will not leave his current, abusive spouse until a new “white knight” is at least visible on the horizon.

Though women have struggled successfully to achieve increased social and career options, they may have had to pay an exacting price in the process: excruciating life decisions about career, families, and children; strains on their relationships with their children and husband; the stress resulting from making and living with these decisions; and confusion about who they are and who they want to be. From this perspective, it is understandable that women should be more closely associated with BPD, a disorder in which identity and role confusion are such central components.

The borderline shifts her personality like a rotating kaleidoscope, rearranging the fragmented glass of her being into different formations—each collage different, yet each, her.

At this juncture Gloria’s fury may be exacerbated as she blames Alex for forcing her into the hospital. But Truth statements should remind Gloria that she is there not so much because of what Alex did, but because of what Gloria did—threatening suicide. The borderline may frequently need to be reminded that others’ reactions to him are based primarily on what he does, and that he must take responsibility for the consequences, rather than blaming others for realistic responses to his behavior.

This kind of problem is especially common within families of borderlines who display prominent self-destructive behaviors. Delinquent or suicidal adolescents, alcoholics, and anorexics may present similar no-win dilemmas to their families. They actively resist help, while behaving in obviously self-destructive ways. Usually, direct confrontation that precipitates a crisis is the only way to help.

Borderlines typically respond to depression, anxiety, frustration, or anger with more layers of these same feelings. Because of the borderline’s perfectionism and tendency to perceive things in black-and-white extremes, he attempts to obliterate unpleasant feelings rather than understand or cope with them. When he finds that he cannot simply erase these bad feelings, he becomes even more frustrated or guilty. Since feeling bad is unacceptable, he feels bad about feeling bad. When this makes him feel worse, he becomes caught in a seemingly bottomless downward spiral.

Although he can work to change this situation in the future, he must now deal with the way things are currently. This means recognizing his anger, that he has reasons to be angry, and that he has no choice but to accept his anger, for he cannot make it disappear, at least not right away. Though he may regret the presence of unacceptable feelings, he is powerless to change them (a dictum similar to those used in Alcoholics Anonymous). Accepting these uncomfortable feelings means accepting himself as an imperfect human being and relinquishing the illusion that he can control uncontrollable factors. If Neil can accept his anger, or his sadness, or any unpleasant feeling, the “feeling bad about feeling bad” phenomenon will be shortcircuited. He can move on to change other aspects of his life.

Adjusting to a world that is continually inconsistent and untrustworthy is a major problem for the borderline.

SET confrontations of object inconstancy require recognition of this borderline dilemma. Support statements must convey that caring is constant, unconditional. Unfortunately, the borderline has difficulty grasping that she does not need to earn acceptance continuously. She is in constant fear that Support could be withdrawn if at any point she displeases. Thus, attempts at reassurance are never-ending and never enough.

Borderline rage is often terrifying in its unpredictability and intensity. It may be sparked by relatively insignificant events and explode without warning. It may be directed at previously valued people. The threat of violence frequently accompanies this anger. All of these features make borderline rage much different from typical anger. In an instant, Pat could transform from a docile, dependent, childlike woman into a demanding, screaming harpy.

Unlike many people afflicted with other mental disorders—such as schizophrenia, bipolar (manic-depressive) disease, alcoholism, or eating disorders—the borderline can usually function extremely well in work and social situations without appearing overtly pathological.

Abby’s case illustrates how a consuming, prominent behavior may actually represent and camouflage underlying BPD, in which one or more of its features—unstable relationships, impulsivity, mood shifts, intense anger, suicidal threats, identity disturbances, feelings of emptiness, or frantic efforts to avoid abandonment—result in psychiatric symptoms that might mistakenly lead to incomplete diagnosis or even misdiagnosis.

It is important to remember that BPD is an illness, not a willful attempt to get attention. The borderline lacks the boots, much less the bootstraps, with which to pull himself up.

However, this does not imply that the borderline is helpless and should not be held responsible for his conduct. Actually, the opposite is true. He must accept, without being excused or protected, the real consequences of his actions, even though initially he may be powerless to alter them. In this way, BPD is no different from any other handicap. The individual confined to a wheelchair will elicit sympathy, but he is still responsible for finding wheelchair accessibility to the places he wishes to go, and for keeping his vehicle in good enough condition to take him there.

After a while, for someone close to a borderline, unpredictable behaviors may become commonplace and therefore “predictably unpredictable.” One of the most common, the angry outburst, usually comes with no warning and appears way out of proportion.

Her husband, Ben, said he was attracted to her “kindness” and “sense of fun.” But Meredith could change dramatically, from playful to suicidal. Similarly, her interactions with Ben would change from joyful sharing to gloomy isolation. Her moods were totally unpredictable, and Ben was never sure how he would find her upon his return at the end of the day. At times he felt that he should enter their home by putting his hat on a stick and poking it into the doorway to see if it would be embraced, ignored, or shot at.

For Meredith, these shifts in mood, unresponsive to a variety of medications, were equally distressing. Her task was to recognize such swings, take responsibility for having them, and learn to adapt by compensating for their presence. When in a state of depression, she could subsequently identify it and learn to explain to others around her that she was in a down phase and would try to function as well as she could. If she was with people to whom she could not comfortably explain her situation, Meredith could maintain a low profile and actively try to avoid dealing with some of the demands on her. A major goal would involve establishing constancy—consistent, reliable attitudes and behaviors—toward herself and others.

Because the borderline may be very creative and dedicated, he can be a most valuable employee. When functioning on a higher level, he can be colorful, stimulating, and inspiring to others. Most borderlines function optimally in a well-defined, structured environment in which expectations are clearly delineated.

At play the borderline is typically unpredictable and sometimes very disconcerting. He may have great difficulty with recreation and play with a seriousness that is out of proportion to the relaxed nature of the activity. He may be your newly assigned tennis doubles partner who at first seems nice enough, but as the game goes on becomes increasingly frustrated and angry. Though you continually remind him that “it’s just a game,” he may stomp around, curse himself, throw the racket, and swear to give up the sport.

The borderline’s intensity interferes with his ability to relax and have fun. Others’ attempts at humor may frustrate him and make him angry. It is virtually impossible “to kid him out of it.”

Thus, those sharing life with the borderline can expect his behaviors over time to become more tolerable. At this point the unpredictable reactions become more predictable and therefore easier to manage, and it becomes possible for the borderline to learn how to love and be loved in a healthier fashion.

Honesty in therapy is therefore of paramount importance for the patient’s sake. He must not conceal painful areas or play games with the therapist to whom he has entrusted his care. He should abandon his need to control, or wish to be liked by, the therapist. In the borderline’s quest to satisfy a presumed role, he may lose sight of the fact that it is not his obligation to please the therapist but to work with him as a partner.

The families of borderlines often balk at treatment for several reasons. They may feel guilt over the patient’s problems and fear being blamed for them. Also the bonds in borderline family systems are often very rigid; family members are often suspicious of outsiders and fearful of change. Though family members may be colluding in the perpetuation of the patient’s behaviors (consciously or unconsciously), the attitude of the family is often “Make him better, but don’t blame us, don’t involve us, and most of all, don’t change us.”

As in individual and group therapy, family therapy approaches may be primarily supportive-educational or exploratory-reconstructive. In the former, the therapist’s primary goals are to ally with the family; minimize conflicts, guilt, and defensiveness; and unite them in working toward mutually supportive objectives. Exploratory-reconstructive family therapy is more ambitious, directed more toward recognizing the members’ complementary roles within the family system and attempting actively to change these roles.

While at one time BPD was thought to be a diagnosis of hopelessness and irritation, we now know that the prognosis is generally much better than previously thought. And we know that most of these patients leave the chaos of their past and go on to productive lives.

There is a Monster in me. . . . It scares me. It makes me go up and down and back and forth, and I hate it. I will die if it doesn’t let me alone.

SET-UP features that were developed by the primary author and discussed in detail in chapter 5: Support for the patient, Empathy for his struggles, confrontation of Truth or reality issues, together with Understanding of issues and a dedication to Persevere in the treatment.

Developed by Marsha M. Linehan, PhD, at the University of Washington, DBT is the derivation of standard cognitive-behavioral therapy that has furnished the most controlled studies demonstrating its efficacy.

DBT posits that borderline patients possess a genetic/biological vulnerability to emotional over-reactivity. This view hypothesizes that the limbic system, the part of the brain most closely associated with emotional responses, is hyperactive in the borderline. The second contributing factor, according to DBT practitioners, is an invalidating environment; that is, others dismiss, contradict, or reject the developing individual’s emotions. Confronted with such interactions, the individual is unable to trust others or her own reactions. Emotions are uncontrolled and volatile.

Mentalization, a term elaborated by Peter Fonagy, PhD, describes how people understand themselves, others, and their environment. Using mentalization, an individual understands why she and others interact the way they do, which in turn leads to the ability to empathize with another’s feelings.