Objectives

• What are the DSM-IV criteria for the borderline personality?

• The mercurial personality is a normal variant of the borderline. Describe its characteristics and relate them to the more disordered criteria of the DSM-IV.

• Explain how different personality styles combine to form each of the subtypes of the borderline personality.

• How does HIV status relate to the borderline personality?

• Borderlines show intense moodiness and rapidly shifting emotions. What, if any, is the connection to affective and manic-depressive disorders?

• Explain the psychoanalytic origin of the term borderline group of neuroses.

• Explain Kernberg's notion of levels of organization as characteristic of the borderline personality.

• What causes a failure of object constancy in the borderline?

• Explain why Masterson and Adler both believed that it is the mother who is ultimately responsible for creating borderline pathology.

• Explain the dynamics of self-injurious behavior in the borderline.

• Describe the interpersonal dynamics of the borderline personality.

• What are the factors that Benjamin considers important in the development of the borderline personality?

• What is the relationship between childhood sexual abuse and borderline pathology?

• Why are borderlines so cognitively dependent on external structures?

• What is the meaning of the term PTSD/borderline, coined by Kroll?

• What are the core beliefs of the borderline?

• Borderlines share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the borderline.

• Why are borderlines such difficult patients in therapy? Why should therapists guard against issues of countertransference when working with borderlines?

• List therapeutic goals for the borderline personality.

To live a life analogous to a soap opera is to live the life of a borderline personality. Wrought with emotional ups and downs, these individuals are known to be unstable and especially angry. What fuels the chaos are intense interpersonal needs and sudden shifts of opinion about others, who may be painted as loving, sensitive, and intelligent one minute and accused of neglect and betrayal the next. When left alone, even for short periods, borderline personalities feel intolerably lonely and empty. With romantic relations typically stormy and intense, they spend most of their time either making up or breaking up. They make frantic attempts to avoid abandonment, including suicidal gestures. In addition, they fail to realize that their clinginess via dramatic and drastic measures drives others away. Plagued by feelings of anxiety, depression, guilt, and inferiority, many engage in self-destructive behaviors, indulging themselves impulsively in drugs or promiscuous sexual activity. Some even mutilate their own bodies by cutting or burning. Lacking a mature sense of self-identity, they flip-flop on goals and values, suddenly change jobs on impulse, and reverse previous opinions with indifference. During stressful periods, this incohesiveness makes them susceptible to temporary psychotic states and dissociative episodes. The borderline personality is peppered with many aspects of other personality disorders. Throughout this chapter, we embark on the roller coaster ride that so aptly depicts this personality.

For the sake of convenience in this text, borderline personalities will be referred to simply as borderlines. Consider the case of Jenny (see Case 14.1). What is immediately striking about Jenny, and about many borderlines, is a specific kind of instability in their relationships. Jenny swings from loving people to hating them and back again, as if she knew only two modes of appraisal: either complete idealization as the best person on earth or devaluation as a demon from Hell (see criterion 2). The immediate recipient of these alternating attitudes is her stepmother, Vera, who is understandably bewildered by such sudden and never-ending shifts of attitude. Later, we find out that Jenny refers to Vera as the "wicked witch" and describes her boyfriend as "evil." Shades of the same are perhaps seen when she talks about her father, who taught her "not to rely on people, 'cause one minute they're here and the next they're gone," as if loyalty could consist only of dichotomous extremes.

What Jenny seems to need most is magical fusion with a loving caretaker. Indeed, feelings of abandonment seem to underlie the intense anger she feels toward her father. Apparently, Jenny sees Vera as replacing not only her real mother but also Jenny herself. A hunger strike, locking herself in her room, and demanding that her father divorce Vera are all frantic efforts to avoid abandonment and recapture the past (see criterion 1). She has also threatened suicide, run away from home, and been arrested for drug possession (see criterion 5).

Moreover, Jenny seems devoid of life goals or consistent values. Whereas normals develop a solid sense of identity that defines the person and gives direction to life, Jenny lacks a stable identity that might anchor her (see criterion 3) against the influence of intense, transient impulses that threaten to seriously damage her life (see criterion 4).

Jenny, age 25, was brought for evaluation by her stepmother, Vera.1 "Sometimes she seems to adore me, and sometimes she hates my guts," Vera said, bewildered. "She knows we love her, but she just goes on and on like this. Sometimes, when it gets real bad, she accuses us of planning behind her back to hurt her." Jenny's efforts to restrain her emotions are obvious. Initial moments of decorum give way suddenly as Jenny bursts forth with an erratic stream of anger, accusation, and feelings of betrayal. The meaning of her words and emotions is difficult to track.

Jenny is no stranger to psychotherapy. According to her stepmother, Jenny was hospitalized in her teens and has been in therapy twice before, each time for about a year. She has an episodic history of substance abuse, including marijuana, alcohol, amphetamines, "ecstasy," LSD, and most recently, cocaine. She has been sexually active since her first intercourse with an older cousin at age 12 and hates to be without a boyfriend. Jenny's mother died of cancer when Jenny was 9. Her father married Vera two years later. Vera's two sons and Jenny's older brother got along well from the start.

Jenny, however, responded to her mother's death and her father's subsequent marriage to Vera with a mixture of withdrawal, anger, and increasingly outrageous behavior. After a suicide attempt, running away from home, and arrests for drug possession, she was deemed unmanageable by the family and sent to a strict boarding school at age 14. She still threatens suicide from time to time, and seems to have no life goals or real values.

Her anger seems total and indiscriminate. She is angry at the circumstances that brought her here. She has just been released from the hospital, where she was recovering from minor internal injuries sustained after jumping out of her boyfriend's Jeep while on the way to a concert, something she has done before. She insists she did it because they were arguing and she was high and just wanted to get away, describing him as "evil." She obviously despises Vera, referring to her as the "wicked witch" several times during the interview.

Her most intense anger, however, is reserved for her father, who "never gave a damn," abandoning her and the memory of her mother by marrying Vera. The worst thing is not his abandonment, she says, but that he doesn't even know he did it. "The only good he ever did was teach me not to rely on people, 'cause one minute they're here and the next they're gone," she continues. She has even gone on a hunger strike and locked herself in her room and demanded her father and Vera divorce.

Jenny believes that he sent her away because she both looked and behaved like her mother, and that her father couldn't handle having a young version of his dead wife in his new life. The death of her mother and alienation from her father have left her feeling "hollow inside," she states. "Sometimes life is like moving in slow motion and I seem like an observer, looking at everything from the outside, numb." Sometimes during these periods she cuts herself with a razor blade, "'cause it hurts, but I end up feeling better afterwards. It shakes me up inside and pulls me back to reality."

Borderline Personality Disorder DSM-IV Criteria

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

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.

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

These include polysubstance abuse and the habit of leaping from moving vehicles to get away from her "evil" boyfriend.

Further, Jenny seems swept up in intense, rapidly changing emotions (see criterion 6), especially anger (see criterion 8). At the beginning of the interview, she makes an attempt at impression management, but finally her anger bursts forth into a stream of accusations. In fact, Jenny seems angry at just about everything all the time. She despises Vera and argues with her "evil" boyfriend. She is angry with her father for marrying Vera and abandoning her and her mother, even though he is unaware of his "crimes" against her. Sometimes, her anger is so intense that she accuses Vera and her father of planning to hurt her (see criterion 9). Perhaps she cannot imagine how life could become so dissatisfying, believing that the course of events would need to be helped along by some evil agency to be so effective in its misery.

Obviously, Jenny feels misunderstood, alienated, and alone. Although everyone feels this way at some time, Jenny reports constantly feeling "hollow inside," apparent evidence of feelings of emptiness (see criterion 7), but probably more closely related to dissociation (see criterion 9). Jenny notes, for example, that life sometimes seems to be "moving in slow motion" and that she is "like an observer" watching things "from the outside," evidence of breakdown in the normally integrated functions of consciousness. To pull herself back from these twilight states, she engages in "cutting," using the undeniable reality of intense pain as a reference point that shocks her back to the real world.

Although subjects like Jenny are well known to many therapists, the borderline construct has proven remarkably controversial. Indeed, the very label borderline presages problems of definition. Logically, anything known primarily for bordering something else obviously cannot be its own entity. Accordingly, it is not surprising that the borderline personality has been reformulated again and again. Zanarini and Frankenburg (1997) note six main historical conceptions:

1. The psychodynamic perspective, which views the borderline as a level of personality organization (Kernberg, 1967) subsuming a variety of character pathologies between neurosis and psychosis.

2. Reflects the influence of the neo-Kraepelinian idea that mental disorders are biological in origin and, therefore, should be diagnosed as discrete categories, as reflected in the work of Gunderson (1984). Though the term borderline clearly contradicts a categorical conception, this approach is nevertheless endorsed by the DSM.

3. Reflects a tendency to experience temporary psychotic states and regards the borderline as existing on a continuum with schizophrenia.

4. Reflects a sudden shifting of emotions, irritability, and chronic depressive states and views the borderline as existing on a continuum with the affective disorders (Akiskal, 1981).

5. Reflects an inability to delay gratification and views the borderline as an impulse control disorder related to substance abuse and the antisocial personality (Zanarini, 1993).

6. Reflects the belief that many borderlines have a sexual abuse history and suggests that the syndrome has much in common with posttraumatic stress disorder (Herman & van der Kolk, 1987; Kroll, 1993).

Each of these threads in the history of the borderline personality has produced its own literature, in some cases amounting to hundreds of articles. In fact, more has been written on the borderline than on any other personality disorder—far too much for comprehensive review and integration. Given its limitations of space, this chapter has two primary goals: first, to review the contemporary and historical issues involved in efforts to define the syndrome, grouped mainly within the biological and psychodynamic perspectives; and second, to provide a discussion of borderline symptoms and traits, thereby giving you a feel for the borderline person, even though controversies and compromises have left the syndrome an admittedly heterogeneous entity.

Given the portrait of Jenny, we now approach additional issues that form the plan of this chapter. First, we compare normality and abnormality; then we move on to variations on the basic borderline theme. Next, biological, psychodynamic, interpersonal, and cognitive perspectives on the borderline personality are described. These sections form the core of what is scientific in personality. By seeking to explain what we observe in character sketches like Jenny's, the goal is to move beyond literary anecdote and enter the domain of theory. As always, we present history and description side by side, noting the contributions of past thinkers, each of whom tends to bring into focus a different aspect of the disorder. Developmental hypotheses are also reviewed but are tentative for all personality disorders. Next, the section "Evolutionary Neurodevelop-mental Perspective" shows how the existence of the personality disorder follows from the laws of evolution. Also included are a comparison between the borderline and other theory-derived constructs and a short discussion of how borderline personalities tend to develop Axis I disorders. Finally, we survey how the disorder might be treated through psychotherapy, again organizing our material in terms of classical approaches to the field: the interpersonal, cognitive, and psychodynamic perspectives.

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