I Hate You—Don't Leave Me (5 page)

Despite her mental and physical problems, Carrie was able to perform her work fairly well. Though she changed jobs frequently, she managed to complete a doctorate in social work. She was even able to teach for a while at a small women's college.

Her personal relationships, however, were severely limited. “The only relationships I've had with men were ones in which I was sexually abused. A few men have wanted to marry me, but I have a big problem with getting close or being touched. I can't tolerate it. It makes me want to run. I was engaged a couple of times, but had to break them off. It's unrealistic of me to think I could be anybody's wife.”

As for friends, she says, “I'm very self-absorbed. I say everything I think, feel, know, or don't know. It's so hard for me to get interested in other people.”

After more than twenty years of treatment, Carrie's symptoms were finally recognized and diagnosed as BPD. Her dysfunction evolved from ingrained, enduring personality traits, more indicative of a personality or “trait” disorder than her previously diagnosed, transient “state” illnesses.

“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.”

A better understanding of Carrie's illness has led to more consistent treatment. Medications have been useful for treating acute symptoms and providing the glue for maintaining a more coherent sense of self; at the same time, she has acknowledged the limitations of the medications.

Her psychiatrist, working with her other physicians, has helped her to understand the connection between her physical complaints and her anxiety and to avoid unnecessary medical tests, drugs, and surgeries. Psychotherapy has been geared for the “long haul,” focusing on her dependency and stabilization of her identity and relationships, rather than on an endless succession of acute emergencies.

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.”

Carrie's journey through this maze of psychiatric and medical symptoms and diagnoses exemplifies the confusion and desperation experienced by individuals afflicted with mental illness and by those who minister to them. Though the specifics of Carrie's case might be considered extreme by some, millions of women—and men—suffer similar problems with relationships, intimacy, depression, and drug abuse. Perhaps if she had been diagnosed earlier and more accurately, she would have been spared some of the pain and loneliness.

Though borderline personalities suffer a tangle of painful symptoms that severely disrupt their lives, only recently have psychiatrists begun to understand the disorder and treat it effectively. What is a “personality disorder”? What exactly does borderline border? How is borderline personality similar to and different from other disorders? How does the borderline syndrome fit into the overall schema of psychiatric medicine? These are difficult questions even for the professional, particularly in light of the elusive, paradoxical nature of the illness and its curious evolution in psychiatry.

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.
^1
,
2

BPD is one of ten personality disorders noted in DSM-IV-TR: in DSM terminology personality disorders are categorized on Axis II. (See Appendix A for a more detailed discussion of categorization in DSM-IV-TR.) These disorders are distinguished by a cluster of developing
traits
that become prominent in an individual's behavior. These traits are relatively inflexible and result in maladaptive patterns of perceiving, behaving, and relating to others.

In contrast,
state
disorders (Axis I in DSM-IV-TR) are usually not as enduring as
trait
disorders. State disorders, such as depression, schizophrenia, anorexia nervosa, chemical dependency, are more often time- or episode-limited. Symptoms may emerge suddenly and then be resolved, as the patient returns to “normal.” Many times these illnesses are directly correlated with imbalances in the body's biochemistry and can often be treated with medications, which virtually eliminate the symptoms.

Symptoms of a personality disorder, on the other hand, tend to be more durable traits and change only gradually; medications are, in general, less effective. Psychotherapy is primarily indicated, though other treatments, including medication, may alleviate many symptoms, especially severe agitation or depression (see chapter 9). In most cases, borderline and other personality disorders are a secondary diagnosis, describing the underlying characterological functioning of a patient who exhibits more acute and prominent symptoms of a state disorder.

Because the borderline syndrome often masquerades as a different illness and is often associated with other illnesses, clinicians often fail to recognize that BPD may be an important component in evaluating a patient. As a result, the borderline often becomes, like Carrie, a well-traveled patient, evaluated by multiple hospitals and doctors and accompanied throughout life by an assortment of diagnostic labels.

BPD can interact with other disorders in several ways (see Figure 2-1). First, BPD can coexist with state (Axis I) disorders in such a way that borderline pathology is camouflaged. 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 Axis I disorder. Although it could be argued that chronic abuse of alcohol could eventually alter personality characteristics in such a way that a borderline pattern could evolve secondarily, it seems more likely that underlying character pathology would develop first and lead to alcoholism.

FIGURE 2-1.
Schematic of position of BPD in relation to other mental disorders.

The question of which is the chicken and which is the egg may be difficult to resolve, but the development of illnesses associated with BPD may represent a kind of psychological vulnerability to stress. Just as certain individuals have genetic and biological dispositions to physical diseases—heart attacks, cancers, gastrointestinal disorders, etc.—many also have biologically determined propensities to psychiatric illnesses, particularly when stress is added to an underlying vulnerability to BPD. Thus, under stress, one borderline turns to drugs, another develops an eating disorder, still another becomes severely depressed.

Third, BPD may so completely mimic another disorder that the patient may be erroneously diagnosed with schizophrenia, anxiety, bipolar disease, attention deficit/hyperactivity disorder (ADHD), or other illnesses.

Schizophrenic patients are usually much more severely impaired than borderlines and less capable of manipulating and relating to others. Both kinds of patients may experience agitated, psychotic episodes, but these are usually less consistent and less pervasive over time for borderlines. Schizophrenics are much more likely to grow accustomed to their hallucinations and delusions and are often less disturbed by them. Additionally, both may be destructive and self-mutilating, but whereas the borderline usually can function appropriately, the schizophrenic is much more severely impaired socially.

“Mood swings” and “racing thoughts” are common patient complaints, to which the knee-jerk diagnostic response from the clinician is to diagnose depression or bipolar disorder (manic depression). However, such symptoms are consistent with BPD, and even ADHD, both of which are significantly more prevalent than bipolar disorder. The differences between these syndromes are dramatic. For those afflicted with bipolar disorder or depression, 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. Borderlines, in contrast, typically have difficulties in functioning (at least internally) even when not displaying prominent mood swings. When self-destructive, threatening suicide, hyperactive, or experiencing wide and rapid mood swings, the borderline may appear bipolar, but the borderline's mood variations are more transient (lasting hours, rather than days or weeks), and more often reactive to environmental stimuli.
³

Individuals with ADHD are subjected to a constant scramble of flashing cognitions. Like borderlines, they often experience wild mood changes, racing thoughts, impulsivity, anger outbursts, impatience, and low frustration tolerance; have a history of drug or alcohol abuse (self-medicating) and torturous relationships; and are bored easily. Indeed, many borderline personality characteristics correspond to the “typical ADHD temperament,” such as frequent novelty-seeking (searching for excitement) coupled with low reward dependence (lack of concern for immediate consequences).
⁴
Not surprisingly, several studies have noted correlations between these diagnoses. Some prospective studies have noted that children diagnosed with ADHD frequently develop a personality disorder, especially BPD, as they get older. Retrospective researchers have determined that adults with the diagnosis of BPD often fit a childhood diagnosis of ADHD.
^5
,
6
,
7
Whether one illness causes the other, whether they frequently travel together, or, possibly, if they are merely related manifestations of the same disorder remains for intriguing further investigation. Interestingly, one study demonstrated that treatment of ADHD symptoms also ameliorated
BPD
symptoms in patients diagnosed with both disorders.
⁸

Borderlines have been demonstrated to reflect paradoxical reactions to pain. Many studies have shown a significantly decreased sensitivity to acute pain, particularly when self-inflicted (see “Self-Destruction” on page 45). However, borderlines exhibit greater sensitivity to chronic pain. This “pain paradox” appears unique to borderlines and has not been satisfactorily explained. Some posit that acute pain, especially when self-inflicted, satisfies certain psychological needs for the patient and is associated with changes in electrical brain activity and perhaps quick release of endogenous opioids, the body's own narcotics. However, ongoing pain, experienced outside the borderline's control, may result in less internal analgesic protection and cause more anxiety.
^9
,
10

The borderline 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 negative medical evaluation.

Dissociative disorders include such phenomena as amnesia, feelings of unreality about oneself (
depersonalization
) or about the environment (
derealization
). The most extreme form of dissociation is dissociative identity disorder (DID), previously referred to as “multiple personality.” Almost 75 percent of individuals with BPD experience some dissociative phenomena.
¹¹
The prevalence of BPD in those suffering from the most severe form of dissociation, DID, as a primary diagnosis is even greater.
¹²
Both disorders share common symptoms—impulsivity, anger outbursts, disturbed relationships, severe mood changes, and a propensity for self-mutilation. There is frequently a childhood history of mistreatment, abuse, or neglect.