Most researchers make a distinction between self-injurious behavior and self-mutilation (Herpertz, 1995). Self-injurious refers to moderate forms of self-inflicted bodily injury such as cutting, carving, and burning of the skin, as well as manipulative suicidal behavior. Such moderate forms of harm to self are characteristic of the borderline personality. Self-mutilation is generally considered to be a wider category that includes self-injurious behavior and other forms of more severe self-harm, such as enucleation, castration, and amputation of body parts. These more severe forms are generally associated with schizophrenic disorders and, on occasion, psychotic breakdowns of transsexual subjects.
Although self-mutilating borderlines usually show more serious suicidal ideation and have more recent suicide attempts than nonmutilators (Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994), self-injurious borderlines generally deny suicidal intent, and the wounds they inflict on themselves are not life threatening. Research (Herpertz, 1995) suggests what may be a consistent set of characteristics. Self-injurious behavior occurs mostly in women, starting in early adulthood and peaking between the ages of 18 and 24. Frustrating external events and a buildup of overwhelming emotions—dysphoria, anger, despair, and anxiety—usually precede an episode of self-injurious behavior. The episode itself seems impulsive in nature and is usually followed by a quick release of tension; it is especially motivating in that most patients report a marked reduction in pain during the episode. In fact, some researchers (Liebenluft, Gardner, & Cowdry, 1987) have found that half of self-injurious borderlines typically report feeling no pain during the episode. These "analgesic" patients appear to constitute a separate subcategory of self-injurious individuals who reinterpret painful sensations and are more prone to dissociative disorders (Russ etal., 1996).
What developmental factors might increase the likelihood of self-injurious behaviors? Parental sexual abuse and emotional neglect during childhood, also related to the genesis of the borderline personality, are significantly related to self-injurious behaviors (Dubo, Zanarini, Lewis, & Williams, 1997). Moreover, self-injurious behavior seems to abate with age, just as borderlines tend to burn out with age. Sadly, for some subjects, self-injurious behavior remains a lifelong practice. At an advanced age, it may include the same self-injurious behaviors along with sabotage of treatment, starvation, and polypharmacy (Wijeratne, Stern, & Howard, 1996).
with their emphasis on internal psychic structures. For most borderlines, being attached to someone rises to the level of a pseudo-biological need, like water or air, as it does for Jenny. Even when securely involved in a relationship, fears of abandonment impose themselves on reality to an almost delusional degree, as if their self-cohesiveness or self-identity might dissolve if the relationship were to end. They may feel, for example, that they are nothing without a certain person, life would be empty without him or her, and their very existence depends on preserving the relationship. To compensate these fears, significant others should nurture, love, and protect the borderline, always be physically available, and never leave. Although Jenny adores Vera at times, she would probably like nothing better than for Vera to simply disappear.
Fears of abandonment are not confined to fantasy, but instead distort borderlines' perception of the communications and actions of others as part of everyday life. They are easily provoked by things that others would never notice. Innocent or irrelevant events or comments may be construed as implying criticism or condemnation. Other events are perceived as their loved one's waning affections or others have refused to consider their feelings or simply no longer care. Even efforts to establish simple boundaries may signify total rejection, the borderline's worst fear. The statement, "I'll be needing the car today at noon," for example, might be taken as implying, "And you won't be coming with me." As a result, minor events are regularly given unintended significance and blown completely out of proportion, producing major interpersonal catastrophes. From the perspective of borderlines, they will soon be cast aside, left lost and alone, with no one to care. The feeling that someone important to the subject is actively distancing may provoke an emergency reaction, punctuated by a tearful, helpless paralysis and a near-manic hyperactive display of anger.
The distortions produced by abandonment fears work to amplify the pathology, producing vicious circles. Significant others cannot be allowed to simply walk away. To secure their attachments, borderlines make frantic attempts to avoid separation. In the normal person, reasonable attempts at reconciliation include taking time out to gain perspective on the issues, suggesting alternatives that might be satisfactory to both sides, or even a mutually agreed cooling-off period. Separation fears, however, leave the borderline with the characteristic mix of panic and rage that usually wears down even the most tolerant individuals. Thus, Jenny goes on a hunger strike, locks herself in her room, and demands that her father and Vera divorce.
In effect, borderlines create the vicious circles they fear most. A mate unable to tolerate such intensity, for example, naturally entertains thoughts of getting out of the relationship. Eventually, fears of abandonment, which originally existed only in imagination, begin to become real. We cannot, for example, imagine that Jenny's boyfriend will want to continue in the relationship when he is described as evil and has to put up with her anger and instability. Inevitably, such thoughts are reflected in the quality of the relationship itself, perhaps through emotional distancing or omissions of nurturance. Borderlines sense these and become angry enough to drive the relationship to the breaking point. Sometimes, they switch to a posture of helplessness and contrition that begs for reconciliation. Alternatively, both parties may be so enmeshed that chaos and conflict become the soul of the relationship. They break up, move out, reconcile, move back, fight once more, and finally break up again, with suicidal gestures and self-destructive, impulsive acting out all the way through.
Consider the case of Elsa (see Case 14.3). Elsa is about to divorce for the third time and is feeling desperate and depressed. Though Elsa and her husband were living apart, there was still hope for the relationship until Elsa began calling her husband four or five times a day, her version of the frantic efforts to avoid abandonment for which borderlines are famous. In response, her husband seems to have realized that the only way out of the vicious circle that was their marriage is to drop Elsa altogether. So he changed his number and moved, and she has no idea of his whereabouts. The pathological source in the relationship becomes apparent when Elsa notes that the marriage gave her "someone to be." The terms of the divorce are generous, but without a solid
A polished and attractive woman of 47, Elsa entered therapy because "I'm just not feeling up to par, and never have." Feelings of depression and despair increased substantially after this, her third, marriage began to dissolve.1 Not yet divorced, but living apart from her husband, she reports extreme anger and feelings of worthlessness at being left helplessly alone. She states that she cannot deal with the situation, and instead spends her time shopping, buying what she cannot afford, drinking too much, and looking for someone to take the place of her husband. "Marital therapy failed," she states, and "after I began phoning him four or five times a day, he has changed his number and moved away. I have no idea where he is."
Elsa seems to have two sides to her. In some ways, she is immersed in the existential angst appropriate to a teenager, still trying to discover "who Elsa really is." In other ways, she seems hard, calculating, and embittered. The anger she feels toward her husband seems inappropriate given that the terms of the divorce are quite generous. Though admittedly not a particularly good relationship, the marriage nevertheless gave Elsa "someone to be." Sometimes her husband is described as "the most loving person," and sometimes as "the asshole."
Instability runs through Elsa's history. She has lost contact with her oldest brother. Her mother's numerous marriages have left her with a combination of half-sisters, half-brothers, and ex-stepsiblings. Family infighting has taken the place of genuine communication. Certain parts of the extended family are divided into factions that no longer speak to each other. Elsa states that she always received the "short end of the stick" when her mother remarried. Because each marriage required a move, Elsa was unable to make lasting friends as a child, and her schoolwork suffered. Her mother didn't care about her grades, and Elsa found it convenient to adopt this apathetic attitude rather than make a real effort in her studies.
Elsa states that although she never really loved any of her husbands, she "completely lost it" when each marriage failed. Probing further, she discloses that she has been hospitalized three times, twice following suicide attempts, once for substance abuse. She received follow-up therapy after each hospitalization, and is being seen by a different therapist at the current time. Initially, she thought very highly of her latest therapist, feeling sure that he would finally get to the root of the problem. More recently, she is disappointed and angry that he is not more readily accessible to her and is unable to see her more than twice a week. Although her visit today seems designed to secure additional nurturance, Elsa will be referred back to the therapist she is currently seeing.
1 Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
(3) identity disturbance: markedly and persistently unstable self-image or sense of self
(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)
(7) chronic feelings of emptiness
(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
(9) transient, stress-related paranoid ideation or severe dissociative symptoms
Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.
identity of her own, what Elsa has lost is herself. In a way, she is like the dependent personality, caught up in a magical fusion with the significant other, only to be devastated when this defining relationship ends. For Elsa, this is a pattern that repeats again and again, and each time she "completely lost it," with attempted suicide seemingly part of the picture. Looking for the next fusion, Elsa has devalued her previous therapist, who is trying to put the brakes on the number of sessions she demands per week. She wants someone new and nurturing.
A second feedback loop relates the consequences of perceived abandonment to self-image. Borderlines frequently feel worthless and empty. Because we tend to regard ourselves as others regard us and because borderlines perceive others as likely to abandon them, they eventually begin to wonder whether abandonment is all they are worth. The tumult created by intense relationships, often in conjunction with a chronic history of physical abuse for sons and sexual abuse for daughters (Stone, 1993), naturally leads to feelings of being empty and worthless, supported by cognitions such as, "I am disposable, and no one will love me," "I am worthy only of being abandoned," and "I exist to satisfy the temporary pleasure of others, not to be loved for myself." We find exactly this in Elsa, for whom depression, despair, and feelings of worthlessness are part of everyday life.
These beliefs are exacerbated by the continuing chaos of interpersonal relationships. Depression is the natural outgrowth of such dynamics, as the case of Elsa shows, as well as suicidal ideation and actual suicide attempts, for which she had been hospitalized. Both can be used manipulatively to coerce nurturance or simply to express anger and resentment. Depression frustrates those who have "failed" the subject or "demanded too much," and suicidal gestures heap guilt onto those who might blame themselves were the attempt successful. Self-damaging impulsive behavior, including classic self-mutilations such as cutting and burning, are both a consequence of the borderline's self-image and a means of shocking or controlling others. One response to feeling abandoned is to abandon yourself.
However, not all borderlines solely desire fusion with a nurturing figure. Fusion brings a powerful intimacy that banishes feelings of emptiness and worthlessness (at least someone thinks enough of the subject to want to merge their two souls together as one), while conferring the equally powerful feeling of being protected against harm. However, fusion also leads to a fear of engulfment. When borderlines do not sabotage their relationships by creating endless cycles of chaos, they may have equally powerful fears of losing their identity in the relationship or of being capsized by the reality of their helpless dependency. The emptiness of not being attached to fantasies of fusion, usually idealization of a magical romantic figure, leads in turn to fears of total dependence on someone else for a sense of self-worth and self-esteem. Greater intimacy exaggerates fears of being vulnerable and exposed, leading back to desires for separation but also to chronic feelings of emptiness, worthlessness, and depression. The answer to this paradox is to never let any relationship become too stable. Here, chaos is not just a pathological outcome but also an instrumental strategy. When relationships become too normal or things are going too well, stability must be sabotaged. By keeping others frustrated and exasperated, the borderline creates a soap opera that keeps each side of the dilemma just barely tolerable. Of the cases discussed, Georgia would be most likely to be caught in this dynamic. On the one hand, she wants to be attached to others, but getting too close makes her feel vulnerable and afraid.
The borderline personality has been examined from the perspective of the SASB by Benjamin (1996). Like other authors, she emphasizes that borderlines fear abandonment and wish to be nurtured. The caretaker secretly wants the subject to be needy, the borderline believes and, therefore, engages a strategy of friendly dependency while undermining his or her own chances for happiness or success. Friendly dependency creates the need for a rescuer, who is quickly idealized. As boundaries between the two are suspended, the subject confides in the rescuer in great detail and begins to make large demands of time. When not enough love is delivered, the borderline devalues the caretaker, now fallen from grace, and switches to a strategy of hostile control, dependency with a vengeance, essentially an effort to milk nurtur-ance from his or her insensitive counterpart.
Benjamin (1996) lists four features in the development of the borderline personality. First is family chaos, which includes factors such as "fights, affairs, abortions, infidelity, drunken acting out, suicide attempts, murders, imprisonment, disowning, and illicit births" (p. 118). Any of these events might be considered tragic, but they contribute to a sense of drama in the borderline family that keeps life safe from boredom. The future borderline often plays some central or pivotal role. The lability of the family, its rapid change of configuration and cohesiveness, models the intense and shifting emotions seen in the adult borderline. We see an example of this in Elsa, the unstable spouse. Her family is split into warring factions that no longer talk to each other; her mother remarried repeatedly, contributing to ongoing instability in the family constellation; and she is no longer in contact with her oldest brother.
Family chaos is accompanied by a second factor: traumatic abandonment. The child, Benjamin (1996) states, is left alone without nurturance, without adequate protection and, importantly, without knowing when the caretakers will return. The implicit message is that the child is abandoned for being bad. During these periods, many children are sexually abused by powerful others, thus laying the foundation for dissociative episodes. Some children "numb out"; for other children, physical pain becomes associated with erotic pleasure. The latter provides one pathway to the later development of self-mutilation. As Benjamin notes, however, not all borderlines are sexual abuse victims.
The third factor Benjamin (1996) discusses seems intended to rein in constructive drives that might allow the future borderline to overcome the past and escape the grip of pathology. The family regards autonomy as bad and "dependency and sympathetic misery with the family" as good (p. 121). Any reason the child finds to believe that he or she is special is met with demeaning punishment, putting the subject back into his or her role as a defective member of a miserable family. The same holds for pride of accomplishment, perhaps even for simple displays of happiness. Genuine joy or constructive striving is simply disloyal. Because we usually treat ourselves as others treat us, future borderlines learn to sabotage themselves whenever anything in life, including psychotherapy, is going too well. The internalized images of early caretakers must be appeased with failure or even self-mutilation. The internal dialogue reads: "If you want me to feel pain, know that I do. I affirm and agree that I deserve punishment and suffering. Here is the evidence. Now you must know how much I love you, and you must love me too" (p. 122). Self-attack thus represents a "gift of love" (p. 122) intended to satisfy vicious introjects. Only when the borderline is totally miserable will those who have been critical and withholding offer nurturance, Benjamin's fourth and final factor.
Focus on Development
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