I Hate You—Don't Leave Me (8 page)

Jennifer (see chapter 1) would fulfill her need to self-inflict pain by scratching her wrists, abdomen, and waist, leaving deep fingernail marks that could easily be covered.

Sometimes the self-punishment is more indirect. The borderline may often be the victim of recurrent “quasi accidents.” He may provoke frequent fights. In these incidents, the borderline feels less directly responsible; circumstances or others provide the violence for him.

When Harry, for example, broke up with his girlfriend, he blamed his parents. They had not been supportive enough or friendly enough, he thought, and when she ended the affair after six years, he was forlorn. At twenty-eight he continued to live in an apartment paid for by his parents and worked sporadically in his father's office. Earlier in his life he had attempted suicide but decided he wouldn't give his parents “the satisfaction” of killing himself. Instead, he engaged in increasingly dangerous behaviors. He had numerous automobile accidents, some while intoxicated, and continued to drive despite the revocation of his driver's license. He frequented bars where he sometimes picked fights with much bigger men. Harry recognized the destructiveness of his behavior and sometimes wished that “one of these times I would just die.”

These dramatic self-destructive behaviors and threats may be explained in several ways. The self-inflicted pain may reflect the borderline's need to feel, to escape an encapsulating numbness. Borderlines form a kind of insulating bubble that not only protects them from emotional hurt but also serves as a barrier from the sensations of reality. The experience of pain, then, becomes an important link to existence. Often, however, the inflicted pain is not strong enough to transcend this barrier (though the blood and scars may be fascinating for the borderline to observe), in which case the frustration may compel him to accelerate attempts to induce pain.

Self-induced pain can also function as a distraction from other forms of suffering. One patient, when feeling lonely or afraid, would cut different parts of her body as a way “to take my mind off” the loneliness. Another would bang her head in the throes of stress-related migraine headaches. Relief of inner tension may be the most common reason for self-harming.
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Self-damaging behavior can also serve as an expiation for sin. One man, guilt-ridden after the breakup of his marriage for which he totally blamed himself, would repeatedly drink gin—a taste he abhorred—until reaching the point of retching. Only after enduring this discomfort and humiliation would he feel redeemed and able to return to his usual routine.

Painful, self-destructive behavior may be employed in an attempt to constrict actions that are felt to be dangerously out of control. One adolescent boy cut his hands and penis to dissuade himself from masturbation, an act he considered loathsome. He hoped that the memory of the pain would prevent him from further indulging in this repugnant behavior.

Impulsive, self-destructive acts (or threats) may result from a wish to punish another person, often a close relation. One woman consistently described her promiscuous behavior (often involving masochistic, degrading rituals) to her boyfriend. These affairs invariably occurred when she was angry and wanted to punish him.

Finally, self-destructive behavior can evolve from a manipulative need for sympathy or rescue. One woman, after arguments with her boyfriend, repeatedly slashed her wrists in his presence, forcing him to secure medical assistance for her.

Many borderlines deny feeling pain during self-mutilation and even report a calm euphoria after it. Before hurting themselves, they may experience great tension, anger, or overwhelming sadness; afterward there is a sensation of release and relief from anxiety.

This relief may result from psychological or physiological factors, or a combination of both. Physicians have long recognized that following severe physical trauma, such as battle wounds, the patient may experience an unexpected calm and a kind of natural anesthesia despite the lack of medical attention. Some have hypothesized that during such times, the body releases biological substances, called endorphins, the body's internal opiate drugs (like morphine or heroin), which serve as the organism's self-treatment of pain.

The borderline undergoes abrupt 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.

Audrey was giddy with excitement as she flooded Owen with kisses after he surprised her with flowers he bought on the way home from work. As he washed up for dinner, Audrey took a call from her mother, who again berated her for not calling to ask about her constant body aches. By the time Owen returned from the bathroom, Audrey had mutated into a raging harridan, screaming at him for not helping with dinner. He could only sit there, stunned and perplexed at the transformation.

Lacking a core sense of identity, borderlines commonly experience a painful loneliness that motivates them to search for ways to fill up the “holes.”

The painful, almost physical sensation is lamented by Shakespeare's Hamlet: “I have of late—but wherefore I know not—lost all my mirth, forgone all custom of exercises; and indeed it goes so heavily with my disposition, that this goodly frame the earth seems to me a sterile promontory.”

Tolstoy defined boredom as “the desire for desires”; in this context it can be seen that the borderline's search for a way to relieve the boredom often results in impulsive ventures into destructive acts and disappointing relationships. In many ways the borderline seeks out a new relationship or experience not for its positive aspects but to escape the feeling of emptiness, acting out the existential destinies of characters described by Sartre, Camus, and other philosophers.

The borderline frequently experiences a kind of existential angst, which can be a major obstacle in treatment for it saps the motivational energy to get well. From this feeling state radiate many of the other features of BPD. Suicide may appear to be the only rational response to a perpetual state of emptiness. The need to fill the void or relieve the boredom can lead to outbursts of anger and self-damaging impulsiveness—especially drug abuse. Abandonment may be more acutely felt. Relationships may be impaired. A stable sense of self cannot be established in an empty shell. And mood instability may result from the feelings of loneliness. Indeed, depression and feelings of emptiness often reinforce each other.

Along with affective instability, anger is the most persistent symptom of BPD over time.
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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. After a disagreement over a trivial remark about their contrasting painting styles, Vincent van Gogh picked up a butcher knife and chased his good friend, Paul Gauguin, around his house and out the door. He then turned his rage on himself, using the same knife to slice off a section of his ear.

The rage, so intense and so near the surface, is often directed at the borderline's closest relationships—spouse, children, parents. Borderline anger may represent a cry for help, a testing of devotion, or a fear of intimacy—whatever the underlying factors, it pushes away those whom the borderline needs most. The spouse, friend, lover, or family member who sticks around despite these assaults may be very patient and understanding, or, sometimes, very disturbed himself. In the face of these eruptions, empathy is difficult and the relation must draw on every resource at hand in order to cope (see chapter 5).

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. Treatment becomes precarious in this situation (see chapter 7), and many therapists have been forced to drop borderline patients for this reason. Most therapists will, whenever possible, try to limit the number of borderline patients they treat.

The most common psychotic experiences for the borderline involve feelings of unreality and paranoid delusions. Unreality feelings involve dissociation from usual perceptions. The individual or those around her feel unreal. Some borderlines 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.

The borderline may become transiently psychotic when confronted with stressful situations (such as feeling abandoned) or placed in very unstructured surroundings. For example, therapists have observed episodes of psychosis during classical psychoanalysis, which relies heavily on free association and uncovering past trauma in an unstructured setting. Psychosis may also be stimulated by illicit drug use. Unlike patients with psychotic illnesses, such as schizophrenia mania, psychotic depression, or organic/ drug illnesses, borderline psychosis is usually of shorter duration and perceived as more acutely frightening to the patient and extremely different from his ordinary experience. 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 recalibrates to usual functioning, unlike other forms of psychosis.

BPD is clearly becoming acknowledged by mental health professionals as one of the more common psychiatric maladies in this country. The professional must be able to recognize the features of BPD to effectively treat large numbers of patients. The layperson must be able to recognize them to better understand those with whom he shares his life.

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. How these markings are formed in the individual and reflected in our society is explored in the next chapters.

Roots of the Borderline Syndrome

All happy families resemble one another; every unhappy family is unhappy in its own fashion.

—From
Anna Karenina
, by Leo Tolstoy

 

 

 

Growing up was not easy for Dixie Anderson. Her father was rarely at home and when he was, he didn't say much. For years, she didn't even know what he did for a living, just that he was gone all the time. Margaret, Dixie's mother, called him a “workaholic.” Throughout her childhood, Dixie sensed that her mother was hiding something, though Dixie was never quite sure what it was.

But when Dixie turned eleven, things changed. She was an “early developer,” her mother said, though Dixie really wasn't sure what that meant. All she knew was that her father was suddenly home more than he had ever been, and he was also more attentive. Dixie enjoyed the new attention and the new feeling of power she had over him when he was finished touching her. After he was done, he would do whatever she asked him.

About this same time, Dixie suddenly became more popular in the family's affluent suburban Chicago neighborhood. The kids began to offer her their secret stashes of pot and, a few years later, mushrooms and ecstasy.

Middle school was a drag. Halfway through a school day, she'd wind up fighting with some of the other kids, which did not rattle her at all: she was tough; she had friends and drugs; she was cool. Once, she even punched her science teacher, whom she felt was a real jerk. He didn't take it well at all and went to the principal, who expelled her.

At age thirteen she saw her first psychiatrist, who diagnosed her as hyperactive and treated her with several medications that didn't make her feel anywhere near as good as weed. She decided to run away. She packed an overnight bag, took a bus to the interstate, stuck out her thumb, and in a few minutes was on her way to Las Vegas.

The way Margaret saw it, no matter what she did, it always seemed to turn out the same with Dixie: her older daughter could not be pleased. Dixie had obviously inherited her dad's genes, always criticizing the way Margaret looked and the way she kept the house. She had tried everything to lose weight—amphetamines, booze, even the stomach operation—yet nothing seemed to work. She'd always been fat, always would be.

She often wondered why Roger had married her. He was a handsome man; from the beginning she could not understand why he wanted her. After a while it was obvious he didn't want her: he simply stopped coming home at night.