THE POLYSYMPTOMATIC NATURE OF BORDERLINE PERSONALITY
THIS CHAPTER IS SPECULATIVE. The view is put forward that the disorders that are so frequently found to be comorbid or in the life history of someone who is eventually given the diagnosis of BPD are not separate and distinct illnesses, occurring as if in a random manner, but are part of the same systematic disturbance, manifest to its greatest degree as BPD. Furthermore, it is suggested that what is common to BPD and the disorders with which it is apparently comorbid is a history of trauma. Such traumata are likely to be of different kinds, predisposing the individual to develop a particular comorbid condition.
In the classic description of Borderline Personality Organization given by Kernberg (1967, pp. 647–648 ), he included, as part of this syndrome, the following features:
1. “Chronic diffuse, free-floating anxiety”
2. “Multiple phobias,” including social phobia, specific phobias, and particularly those phobias “which impose severe restriction on the patient’s daily life”
3. “Obsessive–compulsive symptoms”
4. “Multiple elaborate, or bizarre conversion symptoms,” including those “bordering on bodily hallucinations or involving complex sensations or sequences of movements of bizarre quality”
5. “Dissociative reactions” including fugues and amnesias
6. “Hypochondriasis”
7. Paranoid trends which develop into delusions under certain circumstances; for example, “when classical analytic approaches are attempted in these patients”
The important implication of this description is that patterns of symptomatology now called Axis I disorders are not merely comorbid with BPD but part of it.
The implications of Kernberg’s observations are often overlooked, presumably because they are inconvenient. They upset the apparent tidiness of the DSM compartments. Kernberg’s account, however, is supported by a study using the Symptom Checklist–90–Revised (SCL-90-R; Derogatis & Cleary, 1977). The SCL-90-R reflects most Axis I disorders. It is a 90-item checklist widely used as a measure of general clinical distress. The checklist, completed by the patient, consists of nine subscales measuring somatization, obsessive compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Hull et al. (1993), in charting change in BPD, found that the changes in each subscale were very similar, as if there were a coherence among them—as if they were all part of a single measure. This finding suggested that the measure might indicate change in an aspect of BPD not encompassed by the DSM catalogue of diagnostic criteria.
The comorbidity of BPD with Axis I disorders has been considered by Zanarini, Frankenberg, Dubo, and her colleagues (1998) in an interesting way. The co-occurrences of Axis I disorders in 379 subjects was compared with another group of 125 people who had other personality disorders. A whole range of Axis I disorders could be diagnosed significantly more frequently in those with BPD than in the other group. The illnesses included depressions, panic disorders, agoraphobia, social phobia, simple phobia, obsessive–compulsive disorder, PTSD, somatoform disorders, and eating disorders. The investigators concluded that a “lifetime pattern of Axis I is characteristic of borderline patients” and “a particularly good marker for borderline personality disorder” (p. 1733). This important inference from their data implies that Axis I disorders, when appearing in conjunction with BPD, are not to be explained as random co-occurrences. Rather, these disorders are related to BPD. A later study from Zanarini, Frankenberg, Hennen, and her colleagues (2004) seemed to give further support to the possibility that Axis I disorders are linked to the BPD diagnosis. In a 6-year follow-up of 290 patients, they found that in those whose BPD remitted, there was a decline in the number of associated Axis I disorders, whereas “those whose borderline personality did not remit over time reported stable rates of co-morbid disorders” (p. 2108).
The so-called comorbidity of Axis II disorders with BPD is also considerable. There is an overlapping with other Cluster B personality disorders—that is, BPD, narcissistic, histrionic, and antisocial personality disorders (Fossati et al., 2000; Grilo & McGlashan, 2000; Moldin et al., 1994; Zimmerman & Coryell, 1989, 1990; Zimmerman et al., 2005). Cluster A group, on the other hand, comprised of schizotypal, schizoid, and paranoid personality disorders, overlaps very little with Cluster B (McGlashan et al., 2000). The case is less clear for Cluster C personality disorders, which is disparate. It is composed of avoidant, dependent, obsessive–compulsive, and personality disorder “not otherwise specified.” Dependent personality disorder overlaps with BPD (McGlashan et al., 2000), as does avoidant, though to a lesser extent (Zanarini et al., 1987; Zanarini, Frankenburg, Vujanovic et al., 2004).
Such observations are consistent with the idea that the comorbidity of Axis I and Axis II disorders with BPD is not a random co-occurrence, which is one of the several meanings of comorbidity. It is more in line with the second of the two main meanings proposed by writers on the subject of comorbidities, which is that the conditions are found together because they have a common etiology or pathophysiology, or at least some type of causal relationship between them (Caron & Rutter, 1991; Kendall & Clarkin, 1992; Widiger et al., 1991).
DEPRESSION AND THE EFFECT
OF TRAUMATIC SYSTEMS IN BPD
The most common focus in evaluating the nature of the comorbidity of BPD and Axis I disorders has been the relationship between depression and BPD. Summarizing the outcome of their own work, Levy and his coworkers (2007) conclude that a depression having peculiar qualities is not to be explained as the co-occurrence of two discrete disorders. Rather, “those feelings seem central to the pathology” of BPD. In support of their conclusion, they cite the evidence of Gunderson and Elliott (1985), Westen et al. (1992), and Zanarini, Frankenberg & DeLuca et al. (1998).
Structural equation modeling techniques have been used by Klein and Schwartz (2002) to examine the relationship between BPD and atypical depression, as exemplified by dysthymic disorder (DD). By means of assessing 84 outpatients with DD over 5 years, the researchers tested four competing models of the relationship between DD and BPD symptoms over time. The models were (1) no association; (2) contemporaneous direct effects in which BPD and DD symptoms influence one another over a relatively short time period; (3) lagged effects of a similar kind operating over a longer period; and (4) a fixed common factor underlies both DD and BPD, along with influences that are unique to each condition. The fixed common factor was the best fitting of these models, providing an excellent fit to the data.
A main aspect of the study by Levy and his colleagues (2007) involved the relationship between what can be seen as two IWMs (Bowlby, 1973), or traumatic memory systems, and different aspects of the BPD syndrome. The IWMs were dependent/anaclitic and self-critical/introjective, both of which Blatt and Auerbach (1988) had proposed as central to BPD pathology. In order to consider which elements of the BPD syndrome might be linked to these forms of relatedness, Levy et al. (2007) used the three factors isolated by Clarkin and his colleagues (1993). They found that anaclitic/neediness correlated with all three factors. The self-critical/introjective score correlated only with Factor 1, the self factor, comprised of emptiness, identity problems, fear of abandonment, and unstable relationships. These findings suggest that the phenomenon of BPD might be created by two relatively independent traumatic memory systems, each of which is related to a particular grouping of phenomena.
It is often said that those with BPD might suffer not one, but two or more, kinds of depression, each having a characteristic affective state or mood. The first of these is related to the anaclitic/neediness form of vulnerability, which might result in depression arising from abandonment or fears of abandonment. The second arises from a different vulnerability, and has a different quality. Whether or not it is the same as the ongoing state of “psychic pain” is yet to be determined.
The self-criticism measure is regarded as a reflection of introjective processes in which the critical caregiver or “object” is internalized, so that the subject takes over the role of the object, inflicting the harm that had once come from another. Its most famous formulation came from Freud. The notion of the “critical agency” has been seen as the origin of object relations theory (Ogden, 2002).
Freud’s (1915a) “Mourning and Melancholia” is considered by some authorities to be his most significant work. It was one of the first fruits of Freud’s shift in thinking, the so-called “turning point of the 1920’s” (Laplanche & Pontalis, 1973). It must have been an extremely difficult work to write, since it is unlike his previous theory based on the consequences of unacceptable drives. To read this paper written in 1915 and “Introductory Lectures,” written about the same time, is to enter into two different intellectual universes.
The tone of “Mourning and Melancholia” is uncharacteristically humble, as if Freud were making his way toward a formulation of which he is not yet clear. Freud makes no claim for the universality of his argument. He warns “against any over-estimation of the value of our conclusions” (1915a, p. 243). He finds it unlikely that his proposal will be relevant to all forms of depression so that “we shall, therefore, from the outset drop all claim to general validity for our conclusions” (p. 243). A key passage in “Mourning and Melancholia” is the following:
Let us dwell for a moment on the view which the melancholic’s disorder affords of the constitution of the human ego. We see how in him one part of the ego sets itself over the other, judges it critically, and, as it were, takes it as its object. Our suspicion that the critical agency which is here split off from the ego might also show its independence in other circumstances will be confirmed by every further observation. (p. 247)
This observation concerning “the critical agency” is central to my argument. In this passage, “ego” can be seen as a general word for self or psyche. It was not until the 1930s that Freud eventually distinguished between ego and self (Strachey, 1961). The part of the psychic system that is split off, acting as if independent of the main stream of consciousness, is equivalent to the notion of the unconscious traumatic memory system. This “critical agency” repetitively acts upon the system of self, inflicting the same devaluation, derogation, derision, humiliation—the same wounds—as the original traumatic situation. The association, in the Levy et al. study (2007), between the self factor of Clarkin et al. (1993) and the self-critical/introjective scores in those with BPD is in line with the story of the “critical agency,” since the original source of the criticism is internalized, or introjected, in the BPD sufferer, sometimes experienced as a voice.
HUMILIATION, OR ATTACKS UPON VALUE
According to the theory of introjection, the self-criticism variable reflects traumatic criticism. It is not, however, simple criticism that is traumatic. A particular form of personal damage is becoming increasingly recognized as pathogenic. Its essence is harm inflicted on the positive feeling at the heart of selfhood that gives rise to the sense of worth (Meares, 1999b). These positive feelings have not been scientifically designated. They are, however, often referred to as the tender or intimate emotions. James spoke of “warmth and intimacy” as the feeling at the core of self. This feeling is an essential aspect of the nuclear experiences of personal existence. James sensed this region as a “sanctuary within the citadel” of self (James, 1890, p. 297), which is not to be defiled, devalued, or in other ways violated. Damage to this “self of all the other selves” (James, p. 297) may come through mockery, shaming, or apparently innocuous behavior such as disinterest or lack of response when the child reveals a need for tenderness (see Dutra & Lyons-Ruth 2005, Chapter 9).
The most serious of the various kinds of attacks upon value is sexual abuse, in which the violation of tender feelings is, in the usual case, of greater consequence than the anatomical and behavioral facts of the abuse. A body of evidence now suggests that sexual abuse is the most pathogenic of the various traumata that can be inflicted upon the child, apart from extreme neglect. The harm that comes through physical abuse may come not through pain and terror but most particularly through the humiliation associated with the abuse. Psychical traumata are themselves felt as blows. Derogation, belittling, derision, or whatever it is, is felt like a hit. There is a sharp and instantaneous feeling of distress, and this instant is not connected to the rest of life. It is an interruption in the ongoing sense of personal being. A frequently cited report suggests that the pain of humiliation evokes a pattern of brain response in the anterior cingulate region that is similar to the response induced by pain due to a physical cause (Eisenberger et al., 2003).
Recent findings point to the significance of humiliation in the pathogenesis of atypical depression—that is, a form of depres-sion associated with BPD. In one study, 20 treatment-resistant patients with depression were compared with 20 people who were responsive to treatment (Kaplan & Klinetob, 2000). The treatment-resistant individuals “reported significantly greater levels of childhood emotional abuse, and experienced current day-to-day sequelae of childhood emotional abuse” (p. 597).
Another study concerned 489 subjects who were interviewed and then followed up in order to examine associations between the findings of this interview with subsequent depression (Murphy et al., 2002). “Feeling worthless” at first interview was highly predictive of subsequent depression. In this article reference was made to two other studies with the same findings. In a third study Kendler and colleagues (2003) also found that loss, humiliation, entrapment, and danger predict onsets of major depression and generalized anxiety. In their study 7,322 adult twins were blindly rated on dimensions of humiliation, entrapment, loss, and danger. The authors remarked that “humiliating events that directly devalue an individual in a core role” were strongly linked to risk for depressive episodes (p. 789). Loss and humiliation, when combined, were the most pathogenic events. An example of such a situation is other-initiated separation. These findings replicated earlier studies from London reporting experiences of loss, humiliation, and entrapment among women developing depression (Brown, Harris, & Hepworth, 1995). Another study supported the hypothesis that loss and humiliation are particularly relevant in the provocation of depression onset (Farmer & McGuffin, 2003). It might be supposed that a significant proportion of these findings can be explained in terms of traumatic memory systems concerning devaluation. These symptoms can be triggered by the circumstances of current existence and lead to the onset of clinical depression.
Humiliation and similar attacks upon value are essentially attacks upon self, as previously remarked. The self-criticism variable used by Levy and his colleagues (2007) represents the introjective consequence of such traumata. They showed that a particular kind of depression, measured by the SCl-90-R depression subscale, correlates with self-disturbance in BPD, where self is reflected in scores for identity problems and emptiness.
Another series of reports, although not directly concerned with humiliation and devaluation, showed that an atypical depression, relatively resistant to antidepressant medication, is associated with the background characteristic of BPD: that is, traumata. The depression in these reports is characteristically persisting and resistant to antidepressant medication. Levitan and coworkers (1998), using a community-based sample of 653 individuals with major depression, demonstrated a significant association between early childhood physical and/or sexual abuse and atypical depression but not the endogenous symptoms of depression (i.e., the neurovegetative features). Nemeroff and his fellow investigators (2003) studied 681 patients with chronic forms of depression. They found that those suffering early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect) did not respond well to antidepressant medication and in this way were atypical. Psychotherapy achieved a better outcome.
A Finnish study of 1,405 depressed subjects who were followed up by means of a self-rating inventory 2 years after the baseline screening found that those who remained depressed (n = 217) were more likely to have a history of multiple traumatic experiences than those who recovered (Tanskanen, 2004). Parker’s group found that those women who suffered from childhood abuse developed certain symptoms that are characteristic of BPD. Sexual abuse was associated with deliberate self-harm, whereas physical abuse was related to adult interpersonal violence (Gladstone et al., 2004).
IS TRAUMA THE COMMON FACTOR LINKING
AXIS I DISORDERS IN BPD?
The works of Kernberg, Zanarini, and others suggest that the co-occurrence of BPD and Axis I disorders is not comorbidity in the strict sense of the term when it refers to conditions that are unrelated. It is possible that these illnesses and disorders that coexist share some common etiology or pathophysiology. A hypothesis concerning the common factor can be inferred from a case such as that of Jennifer, briefly described in Chapter 8. She had received multiple diagnoses during her life, in addition to BPD, including anorexia nervosa, obsessive–compulsive disorder (OCD), depression, panic attacks, dissociative identity disorder, and schizophrenia. Her successful treatment by Joan Haliburn, in each of these illnesses, revealed their basis in several forms of interpersonal traumata. The basis of her panic attacks, for example, could be understood in terms of separation–abandonment fears, whereas the OCD was related to an intrusive and controlling traumatic parental background which may provide a specific vulnerability to OCD (Meares, 2001a).
Whether trauma or, more particularly, traumata of different kinds provide the link between BPD and Axis I disorders is a question to which the answer is largely speculative since adequate data are not available. Nevertheless, it is not unreasonable to suppose that within the typically traumatic background of those with BPD, it may be possible to identify subcategories of trauma beyond those coarsely distinguished forms of sexual, physical, and emotional abuse reported in retrospective studies. A more detailed account of these subcategories of trauma appears to be arising from studies of childhood development. Each of these subcategories may contribute to the etiology of a certain proportion of the Axis I disorders. This idea has implications for treatment: It suggests that in those circumstances when a “comorbid” Axis I disorder arises in a patient suffering BPD, the principal focus of treatment should be upon the basic illness—that is, BPD. However, a multimodal treatment regime, specifically constructed for a particular Axis I disorder, is a useful additive measure.
Depression is an example of the polysymptomatic nature of BPD, which is not a single condition but comprises several different mood states that are distinguishable and that presumably have different bases. It is not suggested that all forms of depression that coexist with BPD can be considered aspects of the syndrome. Melancholic forms of depression might be more truly comorbid, suggesting that two kinds of depression can coexist in a person suffering from BPD. In the same way, it is also not suggested that all subcategories of the Axis I disorders can be understood as particular manifestations of the systematic disturbance that produces the patterning of symptoms diagnosed as BPD.
Finally, the multiple patterns of symptoms that may manifest in the life course of someone with BPD may be a further illustration of a basic disconnectedness at the core of BPD. The bases of these symptoms may be conceived as an effect of different systems of unconscious traumatic memory, which are not organized in a single coherent traumatic complex but are largely, though not wholly, disconnected from each other and therefore have different consequences in terms of symptomatology. The polysymptomatic character of BPD, then, mirrors on a much larger scale the broken-up quality of some sessions with the patient who suffers from BPD, in which the effects of various IWMs fleetingly emerge, shifting from one to the other.