Thursday, June 2, 2011

Listening to Borderline

Following is a chopped-down version of part three of an expanded mcmanweb series of articles on borderline personality disorder ...

At first blush, borderline personality disorder appears very much like bipolar disorder, and the DSM symptom list does little to disabuse us of that notion. Thus (symptoms 4-7): impulsivity, recurrent suicidal behavior, affective instability, chronic feelings of emptiness.

John Gunderson of Harvard, in the July 2006 American Journal of Psychiatry, notes that misdiagnosing patients with bipolar, especially bipolar II, is the norm. Periods of depression and irritability are rarely instructive, he says. Neither are sustained periods of elation. What we are really looking for, he informs us, is evidence of a stress connection. Thus:

Repeated angry outbursts, suicide attempts, or acts of deliberate self-harm that are reactive to interpersonal stress and reflect extreme rejection sensitivity ...

In 1975, the legendary psychoanalyst Otto Kernberg of Columbia University theorized that "borderline personality organization" results from the child's inability to integrate positive and negative into a coherent whole. This leads to the incorporation of primitive defense mechanisms that carry on through adulthood. The best-known involves "splitting," in which people are perceived as either all good or all bad, nothing in between.

All-good or all-bad status has a way of changing like the weather in New England, only with far less predictability. Mother Teresa today, Whore of Babylon tomorrow. No in-between. In DSM-speak, we see "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation."

Throw in DSM fear of abandonment, identity disturbance, inappropriate anger, and stress-induced paranoia, and a picture emerges of an extremely fragile individual negotiating a frightening and unpredictable world, at a loss how to respond. As Marsha Linehan of the University of Washington and founder of dialectical-behavioral therapy noted in 1993, "borderline patients are the psychological equivalent of a third-degree burn patient."

Those who live within the blast zone of someone with borderline, however, tend to view themselves as the ones with the third-degree burns. Typically, they describe themselves as constantly having to walk on eggshells. In my own experience, these highly challenging close encounters amount to being forced to dismantle a ticking bomb with seconds on the clock. Do we yank the blue wire or the green one?

Can we calm down an explosive situation or do we duck for cover?

In the closing of the movie "Girl Interrupted," based on Susanna Kaysen's book of the same name, we hear in the main character's voice-over: "Crazy isn't being broken or swallowing a dark secret. It's you or me amplified."

Think of Marilyn Monroe. Her larger-than-life personality combined with her personal insecurities has fed speculation that she may have been dealing with borderline. Likewise, a strong case can be made that she was living with bipolar. Either way, both diagnoses seem to fit. Certainly, Marilyn lit up the world.

But there is also the dark side of borderline to contend with, leaving victims dazed and shell-shocked and violated.

Books such as "Walking on Eggshells" by Paul Mason and Randi Kreger provide excellent pointers on how to protect yourself from borderline meltdowns. For those of us with mood disorders, self-protection is far more urgent. One encounter kickstarted my racing thoughts and messed up my sleep for days on end, putting me at grave risk of spinning into an episode. In another, after one poison pen email too many, the invisible floor that was holding up my emotions gave way, and my mood dropped like a rock. I spent one miserable month fighting off a bear of a depression.

In 2006, NAMI expanded its list of "priority populations" to include those with borderline personality disorder. As a result, their annual convention had on offer an ask the doctors session devoted to this illness, where I had a chance to listen to individuals speaking openly in an environment where they felt safe.

On the panel was a patient – we'll call her Anne – late 30s-early 40s, very smart, very articulate, very personable, with a degree in creative writing. Unfortunately, she told us, the best job she can get is answering phones, and she feels herself lucky. Her illness cannot take the demands of something more challenging, more stressful, that would place her in pressure cooker situations amongst people. When she loses it, she admits, you don't really want to be around her.

As opposed to walking on eggshells, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, she related, and the ground beneath her could collapse any second.

"It's like demons possess me," she on to say. Something inside of yourself so overwhelms you that you want to change it instantly. Such as slitting your wrists, impulsive sex, alcohol, and acting out. She described individuals with borderline as spontaneous and lively and loving until they get hurt. Then they screw up and fall apart. The irony, she said, is people with this disorder want to help so much, but the problem is they have trouble relating to people.

Anne emphasized that people with borderline can change (another speaker referred to the illness as "the good prognosis diagnosis"), and she concluded with reference to her favorite bumper sticker, "Don't believe everything you think."


I do not want wish to leave the impression that I am describing a THEM vs US situation. We all have personality issues we must deal with, and in my observations these often pose a greater problem in our recovery than our actual illness. Accordingly, I urge individuals to study the personality disorders as if each one applied to them.

Psychiatry and its allied disciplines will never figure out personality to everyone's satisfaction (the DSM-5 is working on it), and it would be a sad indictment on our uniqueness as individuals if they ever did. But you can employ these various diagnostic rough guides to connect your own dots, fill in your own blanks, and get to know yourself better.

Further reading from mcmanweb:

Is Borderline Personality Disorder Real?
Borderline Personality Disorder Gains Respect
Listening to Borderline Personality Disorder


Willa Goodfellow said...

Okay, it just astounds me that such a severe illness should be considered an issue of "personality."

John McManamy said...

Hey, Willa. Really good point. With this illness, we definitely have a riddle wrapped in a mystery inside an enigma. Depression and bipolar is a piece of cake next to borderline. I think two things are going on: 1) Faulty view of reality (such as highly distorted views of self and others), and 2) extreme vulnerability to stress.

The combination means those affected are literally ALWAYS in the illness state rather than in episodes. If they are not melting down, they are behaving in ways to control their frightening world to keep from melting down. This "always" condition ("pervasive pattern" in DSM-speak) indicates we have, in effect, a disease of the personality, or an illness that profoundly affects personality.

With bipolar, our illness may influence our personality, but there is a clear separation. "Uncharacteristic" is the key word. When we are in an episode, we are outside of our usual patterns, not conforming to a "pervasive pattern."

When we gain control again, we revert to our "normal" selves. With borderline, it seems, normal and the disease state are one. Reality is always distorted, the danger of melting down is always there. I think this is why borderline is considered an issue of personality.

But any attempt to try to explain - by anyone - is only going to come across as simplistic. There are no simple answers to this. But looking for answers undoubtedly assists us in our understanding. So please keep shooting me observations and I promise to keep scratching my head.

Lizabeth said...

Ok, one part of Borderline I completely understand. My mother was British and in charge of an antiaircraft gun in London during the WWII Blitz, my father was a Canadian MP in Germany during the Occupation. All my aunts and uncles that I knew growing up in Canada were in the Service one way or another. The end result---I never believed the world was a safe place. I think people that do believe that it is are deluding themselves.

Oh--and we had to move to the US when I was 11 because there was a strike/lockout against my Dad's union and he could not get a job in Canada, as a result of a highly illegal, but invisable and effective blacklist. You can respond to an unsafe world in an effective way like we did by moving. But there is no convincing arguement of safety, its a matter of how you cope. At least in my opinion.

John McManamy said...

Great points, Lizabeth. Yes - it's all about coping. This is what the Freudians believed and they are right. They are only wrong in the sense that they didn't recognize the biology of the process. They associated mental illness with maladaptive reaction to life.

But I do think safety comes into it - at least PERCEPTION of safety or unsafety. If the world SEEMS unsafe, then life is going to be extremely stressful and mental illness will follow like night follows day.

If you feel you can cope with life, there's going to be a lot less stress.

So, here you are, blacklisted in a hostile world. But you cope.

Now reverse it. No blacklist, things perfectly normal, but the individual reacts AS IF he or she were living in a blacklist situation. The faulty perception creates the impression of being unsafe which creates stress and various behaviors.

Again, I'm not claiming to have any answers. Your comments, though, are really making me think. Keep commenting. :)

Moira said...

We should probably let the dead rest in peace, but I'm glad you resurrected briefly Marilyn Monroe to shake and shimmy and show the complex behaviors fashionably labeled borderline or bipolar or both these days. How about reactive attachment disorder for Marilyn? That's a popular label now, too, for persons abandoned, in foster care, from orphanages.

I'm of the label jars and not people school. Regardless of labels pinned on, I want to know how modern medicine would treat Marilyn today, if she were alive today and in whatever condition her condition was in?

I found this quote from Marilyn Monroe in goodreads: "I'm selfish, impatient and a little insecure. I make mistakes, I am out of control and at times hard to handle. But if you can't handle me at my worst, then you sure as hell don't deserve me at my best."

There's an exhibit of rare photos in the Andrew Weiss gallery in New York to honor Marilyn's 85th birthday.

Happy birthday, Ms. Marilyn. You will live long in the public memory as a love goddess, as an artist. You're a candle in the wind. These labels burning--they smell like breaking wind.

Summer said...

Thank you for your posts on Borderline.