12

Between Actualpathology and Psychopathology: Post-Traumatic Stress Disorder and Borderline

POST-TRAUMATIC STRESS DISORDERS

The diagnosis of post-traumatic stress disorder (PTSD) is becoming increasingly common today, suggesting that the clinic has returned to its original starting point (Freud and Breuer 1978 [1895d]). Associated with this is the success of the concept of borderline personality disorder, whose link with a traumatic history is becoming progressively clearer (Herman 1992b). The argument of this chapter will be that both can be understood as situated between the actualpathology and the psychopathology positions, albeit with a very clear stress on actualpathology.

At first—naive—sight, the diagnosis of PTSD doesn’t present too many problems. It is one of the few DSM diagnoses that has an etiology. The underlying logic is this: Trauma is an actual, but thankfully relatively uncommon event, and the psychological confusion (that is, disturbance) it causes is not only foreseeable but above all entirely comprehensible. Treatment ought to follow as soon as possible afterward, and the victim will automatically request help.

In practice, things are quite different. A review of virtually all the English language publications of empirical research into PTSD over the period 1990–2001 produces the following surprising results (Lee and Young 2001; Paris 2000; Perkonigg et al. 2000).

Firstly, the experience of trauma (as defined by the DSM-IV) is fairly common. More than half the normal Western population sooner or later undergoes such a shattering event. Paris (2000, p. 179) comments dryly: “Throughout history, trauma has been more the norm than the exception in human experience.” This is followed by the remarkable conclusion that from this large group only a limited number will effectively develop PTSD. The average figure oscillates between 1 and 9 percent (Paris 2000) and 5 to 12 percent (Lee and Young 2001). Thus we must conclude that trauma in itself is not enough to cause later, longer-lasting disturbances. In most cases, it is immediately after the trauma that an acute stress disorder appears (ASD in the DSM-IV, 308.3), lasting a minimum of two days or four weeks maximum. Its subsequent development into a PTSD is rare (Harvey and Bryant 1999).

This brings us to the second conclusion: the occurrence of PTSD is determined not so much by the trauma itself as by other factors. The question then becomes, Which other factors? The obvious answer in our genetically colored times is heredity.¹ Behavioral genetic studies on twins have indeed shown a genetic disposition. Nevertheless, this must be qualified with the following two points: the same behavioral genetic studies demonstrate first of all that the supposedly inherited disposition is nonspecific and can give rise to different pathologies; secondly, environmental factors are responsible for half the variation in nearly every dimension of personality. Moreover, it was also shown that traumatic environmental factors are the cause of long-term neurobiological changes (Paris 2000, pp. 177–178). In other words, we come up once more against the eternally complex imbrication of nature and nurture as determinative of the end result.

A third conclusion further relativizes the importance of actual trauma. Counter to all expectations, there is no relation between trauma and pathology with regard to the nature or burden of what the victim literally experienced. This seems to be true even for long-term physical and sexual abuse of children: “Such research has consistently shown that exposure to child abuse increases the risk of developing a wide range of psychological symptoms, but that only a minority of exposed persons are likely to develop clinically significant psychopathology” (Paris 2000, p. 176). What research has proven is a connection between the development of PTSD and certain personality characteristics existing before the traumatic event and the repetition of the trauma.²

This brings us to the final conclusion of the research from the previous decade. Undergoing traumatic events can cause a number of other psychopathological disorders than PTSD, particularly depression, addiction, and personality disturbances. Comorbidity is less the exception than the rule, and in a large number of cases the other disturbances will appear in isolation, that is to say, without an obvious PTSD present.

Complexity

The diagnosis that seemed so easy at first sight is clearly somewhat more complex, and the question moves from the nature of the trauma to the structure of the subject. Depending on this latter, the reaction will either be limited to an ASD, or a more extensive disorder will develop later. One can even see this shift in emphasis in the evolution of the DSM, the most recent edition of which introduced subjective factors into the diagnostic criteria for PTSD (Lee and Young 2001, p. 151).

To make sense of these subjective factors, we must call on the theoretical foundation set out in Part II of this book. My thesis has already been stated: trauma must be understood in terms of actualpathology. But before going more deeply into this, let us first present a number of arguments in support of this view, which can be found in just about every study and research discovery. Firstly, anxiety is the central phenomenon of the clinic. This is why PTSD is classified in the DSM under the heading of anxiety disorders. This anxiety has a very distinct nature: there is no secondary processing, and its manifestation is quite similar to anxiety neurosis and panic attacks.

Secondly, and immediately following on from this, it is impossible for such patients to arrive at a normal, that is to say, associative representation and elaboration of the trauma. This brings us to the problem of memory functioning. It is striking how normal, associative memory fails to function in cases of trauma. In its place appear intrusive phenomena that attack the subject with (fragments of) the raw, nonprocessed trauma. For some authors this is the primary differential diagnostic characteristic (“Intrusive imagery is the hallmark of PTSD”; Lee and Young 2001, p. 151). This is then also the chief common factor between the different descriptions of the ICD-9 and the DSM-IV.

The two previous characteristics already show how psychological processing through a secondary elaboration is not simply absent, but is evidently in itself inherently difficult. My third argument for situating PTSD on the side of actualpathology therefore comes as no surprise: in practically every case we will encounter somatization. Lacking the possibility of being psychologically processed, the Real of the trauma is inscribed onto the body itself. The high frequency of the coincidence of trauma with addiction points to the same thing: patients try to treat their problems by intervening directly with their body.

Finally, I would like to mention something that is less frequently mentioned in diagnostic studies but that comes out all the more during the treatment: the primary effect of chronically traumatic situations on subject-formation. This is particularly clear with regard to the so-called dissociative phenomena that split the psychological functioning in two, but it also contributes to the difficulty of further secondary processing.

Situating PTSD on the side of actualpathology, as I do, has two important diagnostic implications. Since PTSD belongs to the actualpathological spectrum, it can occur just as easily in neurotic, psychotic, and perverse subject structures. Contemporary research literature ignores this, and even Freud (1978 [1920g]) spoke exclusively about traumatic neurosis. Nearly every study surreptitiously assumes an underlying “normal” structure, with the result that PTSD in psychosis and perversion is hardly ever addressed. The connection between trauma (concentration camp victims) and schizophrenia has been forgotten (Bettelheim 1979). In the study of perversion, the connection between the perpetrator and early infantile sexual abuse is often made, but never, or rarely the reverse: perversion is almost never mentioned in studies of PTSD. The result is that many clinicians take an underlying “normal” neurotic structure for granted.

The differential diagnosis becomes even more tricky in light of the fact that trauma doesn’t necessarily lead to an exclusively actualpathological problem. One can find traumatic antecedents in many psychopathological case studies, so one must assume that a number of patients are indeed able to process the secondary elaboration. Again, the question shifts to the structure of the subject itself, as the mediating factor between the actual trauma and the potentially pathological effects.

PTSD as Actualpathology: Structural versus Accidental Trauma

As during the era when the psychotherapeutic clinic began, it has recently seemed as though the cause of all psychological disturbances could be brought back to trauma. In the early days, this became nuanced by the unavoidable discussion of “false memories” and real traumas, a discussion that has returned to us today. My thesis will be an extension and fuller confirmation of this starting point: not only psychological disturbances but all development begins with what I have called the structural trauma (Verhaeghe 2001b, pp. 49–64). How this structural trauma is—or is not—elaborated through the Other will lay the foundation for potential later disturbances, including PTSD. These disturbances will always involve a repetition, through an accidental trauma, of the original structural trauma and its failure to be processed.

As we saw in Part II (Chapter 6), subject-formation begins with an internal experience of unpleasure that is caused by the drive. The impossibility of regulating this is the result of the child’s physical helplessness and its accompanying inability to represent the drive. Representation is the necessary condition for the subject to be able to regulate the drive. Such representations, along with the specific actions that release the tension, come from the Other and will set identity acquisition into motion from that moment on.

This means that subject development begins initially with the structural trauma, that is, in the confrontation between the subject-to-be and the nonregulated rise in tension, caused by the wordless Real of the drive. Right from the start, we encounter the principal characteristic of all trauma, namely, the absence of normal, associative representation.³ In the same movement, the trauma is introduced into the initial relation between the subject and the Other, thus adding an essential element: as a consequence, not only is the drive tension traumatic, but the absence of the Other also comes to carry the same traumatic weight. In that sense, every trauma is at the same time a trauma of separation.

In a secure development, the Other is safely present, offering the guaranteeing signifiers necessary for opening up the ongoing possibilities of representation and elaboration, both for the tension of the drive and the corresponding identity. Both the nature of the original relationship between the subject and the Other and the signifiers that the Other presents will determine the subject’s increasing possibilities for representation and elaboration, this being nothing other than subject-formation.⁴ Many things can go wrong during this process as well, but because of this elaboration such disorders will belong to the psychopathological spectrum.

Studies based on attachment theory have shown that if the original attachment has been sufficiently secure, the subject will have a firm enough basis to process potential accidental traumas later on. Processing implies that, while an ASD may well appear following an accidental trauma, there will be no further progression on to other pathological disturbances. In fairness, we can assume that such an accidental trauma gives rise to a processing analogous to that of the original trauma, that is, to an appeal for and intervention by the Other, in this case an already interiorized Other; it is precisely this processing that inhibits further progression into PTSD.

In cases where the original processing of the structural trauma and the accompanying separation either failed to take place, or took place insufficiently, one can predict that subsequent accidental traumas will not be processed normally either. Attachment theory calls this type of attachment group “unresolved.” Quite so; the original problem of (a) was indeed not “solved” and it is precisely this that will give rise to a further disturbance, built on the already existing subjective structure and the nature of the accidental trauma.

In such cases we will once again encounter the characteristic actualpathological phenomena, recognizable from their lack of processing through the signifier, and with emphasis on primary anxiety and somatization. If our line of reasoning is correct—that PTSD is a regression to the subject’s preexisting actualpathological position—this position ought to be visible and detectable prior to the development of PTSD resulting from an accidental trauma. This presence is confirmed by a large-scale epidemiological study (N = 3021) of the so-called premorbid personality, demonstrating that more than 60 percent of the patients already had a preexisting disorder, particularly somatization disorders (63.6%), social phobias (62.2%), or simple phobias (71.4%) (Perkonigg et al. 2000). From our perspective, this seems quite telling, as it points in the same direction: there was no or only insufficient original processing of (a) through the Other, hence the somatization and (social) phobia.

Such a regression to actualpathology resulting from an accidental trauma implies a renewed confrontation with the unprocessable, an inner rise in tension that Lacan calls “jouissance.” The peculiarity of this term notwithstanding, it can easily be recognized in contemporary terminology as post-traumatic stress disorder. The word stress gives a poor indication of what patients internally experience as an unbearable rise in tension and anxiety that they often try to put an end to through automutilation and dypsomania. Freud (1978 [1920g]) came up against this too. It is far from coincidental that his most significant paper here is called “Beyond the Pleasure Principle.” What traumatic patients repeat is anything but pleasurable, and yet the repetition continues to function as an attempt at mastery nonetheless. For Freud, this takes place through the “binding” of the energy to word representations; for Lacan, through the signifiers of the Other (see Chapter 9, Note 20).

Certain research data on accidental trauma in children confirm this. Time and again it becomes clear that it is the parents who must provide the child the language through which the trauma can be processed. By this we must understand, so as to be able literally to re-member it,⁵ enabling the trauma to be emotionally regulated (Salmon and Bryant 2002, pp. 174–176). The worst possible thing to do is what many parents end up doing, namely, keeping quiet about it so as to forget as quickly as possible (Yehuda et al. 1998).

One study reveals something striking. As had been anticipated, the children of Holocaust survivors run a higher risk of PTSD compared to other children. What is remarkable is how these children display far more PTSD disturbances than their parents (Yehuda et al. 1998). Naturally this is very delicate material to interpret. From our perspective, this could indicate that the central mediating factor is not so much the actual traumatic experiences themselves but the Other. The same thing is confirmed by studies on the impact of the social environment, with the Other as a social-cultural discourse. The presence or absence of social support quite clearly influences the appearance of PTSD (Paris 2000, pp. 179–180). This explains, for example, why Vietnam vets suffered many more traumatic disturbances than their World War II cousins. The latter were seen as heroes; the tickertape parades on Fifth Avenue and elsewhere were all-inclusive. The former were jeered after their “tour of duty” and, above all, forced to keep quiet about their experiences.

A further confirmation of our thesis is found in the conclusion that trauma is especially traumatic when it is repeated. By original trauma, these studies refer not only to actual experiences that can be neatly isolated, but more particularly to so-called “life experiences” (see Craig et al. 1993). These are fairly extensive, but can be summed up in terms of underprivileged circumstances, early infantile abuse, and early separation from the parents. What is central, particularly in the last two cases, is either the absence or the dysfunction of the Other. This is quite closely connected with another given of clinical experiences, namely, that one frequently finds an increased separation anxiety in cases of PTSD (Perrin et al. 2000, p. 278; Yule 2001). The traumatic experience drives us back toward the Other.

A clear analogy can be made, moreover, between our line of reasoning and contemporary ideas about the cognitive processing of those life experiences. “Cognitive” is the fashionable word today for “psychological,” and has the disadvantage of suggesting that the emotional-affective element is not involved. Even within this cognitive approach, one begins from the idea that the trauma has to be “encoded” (“the attribution of meaning”) through the construction of “schemas” or “constructs,” which are “cognitive-affective memory structures and beliefs” (Cason et al. 2002). This is based on the understanding of the psyche as an information processing and associative system.⁶

This description is not far from what we developed earlier but it misses the crucial point, namely, that the development of such “constructs, responses, and meanings” occurs through the Other, and that it is in the course of this development that the subject’s identity, the identity of the Other, and the outside world emerge. This is not merely a difference in diagnostic outlook, it has serious repercussions for the treatment. In the cognitive approach, it seems as though it is enough just to confront the patient with new and, above all, corrective information, “resulting in new learning and more diverse, elaborated associative connections” (Cason et al. 2002, p. 148). It is, in other words, a University discourse, as described in Part I of this book. The fact that this new information can only be taken in from within the framework of a therapeutic, workable relation with the Other, and that this relation acquires all the weight of the preceding primary relation, moreover, making the process therefore far from self-evident, has received far too little attention. At most, we hear about the patient’s “resistance” to the new information, which we are told we must understand as the patient’s resistance to the therapist as the Other.

All of this proves that there are sufficient arguments for tracing the distinction between a restricted ASD and the larger PTSD back to the preceding, unresolved actualpathological position. Subsequent actual trauma will always have a retroactive effect that depends on this preceding position.⁷ Both the diagnosis and the treatment must take this fully in account. Our explanation began with the idea of a temporal split between an original, unprocessed structural trauma, and a later accidental trauma. In clinical practice, however, we encounter yet another situation where the structural and the accidental trauma are intertwined with one another. This occurs in cases of chronic sexual and/or physical abuse of children, and will not only result in a classic, actualpathological position, but will also have serious effects on the subject-formation itself. That is why this group must be treated separately here.

Early Infantile Abuse and Subject-formation: Basic Distrust, Dissociation, Passive–active Reversal

Ordinary development takes place in a situation of what Anglo-American psychoanalysis calls “basic trust”: the Other assumes a regulating and caretaking function through which identity development and drive regulation come into being. The confrontation with (a) can be processed through signifiers coming from the Other. In cases of chronic sexual and physical abuse, however, we encounter exactly the opposite, namely, “basic distrust”: the Other as a guarantee is not installed, the drive has not been psychologically elaborated. Not only is the internal drive insufficiently processed, a confrontation with the Other’s drive takes place on top of that.

The effects of this on subject-formation are far-reaching. As we saw in Part II, through the normal dialectics of alienation and separation, identity formation initially takes place by way of a dual mirroring with the Other, and later through a triangular distancing of this Other. In this way, a synthesis of different identifications comes into being and the Ego is developed. At the same time, the Other’s identity is internally represented, along with the relationship toward this Other. In both identities, the good and bad parts are integrated. From the classical Freudian perspective, this leads to the so-called dynamic unconscious where the pleasurable and the unpleasurable parts operate in an associative network, and where the splitting of the subject is never complete. It is precisely this aspect of integration that fails to be installed in cases of chronic child abuse. In its place, dissociation is installed.

This idea seems a recent one, but in fact it is not. It is just a contemporary translation of Freud’s original concept of the unconscious, formulated precisely during his clinical work with traumatized patients. In this early period, he discovered how such patients’ psychological functioning entails a radical Spaltung, a splitting, where one part is associatively separated from the other. At first it was only in what Freud called severe cases of hysteria that this splitting was recognized, but let us not forget that he was working with traumatic disturbances at the time (Freud and Breuer 1978 [1895d], pp. 12–13). Later, once he began to concentrate on the psychoneuroses, he had to conclude that such a splitting is found in these patients as well, albeit in a much less radical way: the conscious and unconscious run through one another, and the patient is able to make associative connections.

In dissociation this doesn’t happen. There, a split between the unpleasurable, “bad” part and the pleasurable “good” part of the Other is installed. This split is mirrored in the subject in such a way that it installs a analogous split between the “bad” (because abused) and “good” (because “normal”) parts of identity. Such a dissociative splitting comes into being as a defense during the abuse: the child “switches itself off” and is psychologically “gone”; the child itself is not being abused, only the “bad” part, and by the “bad” part of the other, moreover.⁸ After the abuse, a return to the preceding situation that was cut off takes place, allowing the “normal” relation between the subject and the Other to function once more. In some cases, dissociation becomes a system according to which the identity of the different “alters” can be distinguished, that is to say, through subidentities who function completely independently of each other. The relation with dissociative identity disorder is clear.

As a defense, dissociation has a clear advantage. The child needs the Other, the relation cannot be severed.⁹ Through the radical splitting, both can continue to function in a seemingly normal relation. The loss is nevertheless immense. The Symbolico-Imaginary processing of the dialectics between (a), subject, and Other through the normal Oedipal structure is impossible. As a result, there can be no symptom formation either. In its place, actualpathological phenomena are formed, together with repetition compulsion.

Such phenomena contain the primary anxiety and somatization, but here the latter in particular appears in a much more severe form. Because of the repeated abuse, the child lives in a constant state of anxiety and alertness (“When will ‘it’ happen again?”) that establishes a chronic hyperactivation in all bodily systems. After a while, this leads to exhaustion, with diffuse effects on the body (heightened blood pressure, digestive disorders, sleeplessness) and, finally, the hyperalertness reverts into the opposite, that is, a general numbness.

The repetition compulsion operates monolithically, intrusively, and incomprehensibly. Fragments of the abuse impose themselves through “intrusive imagery,” frequently found in the play of small children in performative ways. These intrusive phenomena are often triggered by minimal cues in the environment, setting the reexperiencing of the trauma in motion, and instigating the flip from one side of the dissociation to the other.

As far as identity development is concerned, there is no integration through triangular distancing, to the contrary even. The world, and therefore others, are seen entirely in black and white, and defined as either good or bad, with very rapid switches between the two. The same goes for the subject’s own identity. The general relation toward the Other is similarly characterized by such a splitting—either he or she is entirely trustworthy, or completely untrustworthy. The regulation of the drive either runs through aggressive automutilation, or through projective identification, where the bad part of the subject’s identity is usually projected onto the other in an attempt to master it. Here we find a passive–active reversal in an attempt at mastery; rather than taking on the role of victim oneself, it is the Other who must become the victim. Such projective identifications are often accompanied by forceful actings-out, setting a vicious cycle in motion (see Chapter 14). As adults, these patients may display a strange combination of sexual promiscuity and anxiety about intimacy.

The result is a combination of a number of disturbances, almost always in the actualpathological range, with an emphasis on acting out and aggression, often in combination with addiction. These make it difficult to see the traumatic ideology underyling the initial reasons for the consultation that almost always occurs at the demand of a third party.

The Nature of the Trauma and the Handling of Guilt

The majority of recent empirical studies are concerned with the characteristics and classifications of PTSD. Because most studies have no foundation in a metapsychology, this means that such classifications tend to be pretty arbitrary—the DSM again being the best example of this. We will shortly examine the DSM category of PTSD in light of the above-described structure, namely, the retreat to an earlier actualpathological position through an accidental trauma. But before we go into this, let us first look at another classificatory criterion: the nature of the accidental trauma.

As mentioned above, factual experience is of less significance than the structure of the subject, but this doesn’t mean we can ignore these facts! We must distinguish between an individual and a collective trauma—which itself can be further differentiated on the basis of its acute or chronic nature. Typical collective chronic traumata are war situations, but also the sexual abuse of a number of children in the same family. Temporally isolated accidents or disasters are collective acute traumata. Both may also involve merely a single individual, which is not without its own effects, particularly in the way guilt is experienced. The difference between these different forms must be taken into account in the differential diagnostics.

A typical example of an acute, individual trauma is rape. In most cases, the resulting ASD will not give rise to a PTSD, particularly if there is enough support from the surrounding environment. Such support always boils down to the same thing: the ability to talk and talk and talk again, within a guaranteeing supportive relationship. Hence the complaints of rape victims of former times: the police didn’t listen to them, did not take them seriously—luckily this has since changed. The guaranteeing function is even more expected from those in positions of authority. Where such an embedment in the signifier is missing, the chance of later disturbances is increased. This will be even truer in cases of a preceding actualpathological position. Moreover, the two will interact. Because of the actualpathological position, the victim will be unwilling to talk about the recent trauma in any event, with the result that the surrounding environment will remain silent as well, and so on. In such cases the demand for help will not be so evident.

The most frequent form of chronic individual trauma, child abuse, has already been discussed. Its most visible forms are physical and sexual abuse, but that doesn’t mean that abuse can’t happen without such acts. I am referring to situations where children grow up psychically terrorized, without a single hair of their head being touched, as it were. This latter may indeed be taken literally, and immediately shows the poverty of positive affect in such a psychologically traumatizing upbringing. These patients, moreover, don’t have the relative advantage of being able to point to objective factual abuse, while the effects can be at least as severe.

In both cases, what initially seems like a remarkable phenomenon emerges, one that is less apparent in the collective forms of trauma, namely, the victim’s sense of guilt, or “survivor’s guilt.” The public’s inability to understand this is immense: How could this be? Not only did the poor victims have it happen to them, they feel guilty now? The well-meaning answer is then to press the role of victim onto the subject, forcing patients to remain silent about this sense of guilt, yet without freeing them from it. Where does this sense of guilt come from? For the answer we must look once more at the way the original structural trauma failed to be processed. In the dual relationship with the Other, there are only two options: either the responsibility is laid on the other, or the subject takes it upon itself. In cases where the Other doesn’t respond, all the subject can do is take the guilt upon itself, and this is precisely what happens in these patients. Mostly they will rationalize this sense of guilt, which comes down to a way of coping with anxiety: “If I hadn’t done this or that, then ‘it’ wouldn’t have happened.” Or—and typically along the lines of the original trauma—during the course of the treatment of sexually abused patients, the other will be blamed, usually the mother who could not or did not want to see “It”; she failed to intervene, to notice, and so on (remarkably enough, the perpetrator tends to be blamed less).

The two final forms are the collective traumas, whether chronic or acute. Acute trauma involves a single disaster situation for a group, while chronic trauma is usually associated with war situations. From a diagnostic point of view, the relative advantage is that the etiology is known—which isn’t always the case in the two forms discussed earlier. Their chief difference from the previous, individual forms is that in case of collective trauma the question of guilt is handled differently because of the way the event was shared with others. The processing will almost always happen in the group, which in it itself creates the possibility for the construction of a collective discourse—an Other—that enables the Real to be more smoothly embedded in the signifier. Here, as before, the foundation for a subsequent appearance of PTSD will always have to do with a preceding actualpathological position.

To conclude this introduction, we must mention one more striking fact, namely, that there is often a time lapse between the trauma and the appearance of PTSD, sometimes even a long one during which there have seemingly been no troubles at all. The DSM specification includes “with delayed onset” when the disturbance begins six months or even more after the event (Hermann and Eryavec 1994; Solomon et al. 1991a,b; Solomon and Singer, 1995). The explanation must be sought in the typical characteristic of the actualpathological position: there is no speech, the “elaboration” takes place in silence. Even more, in many cases such patients don’t want to know about it and actually know nothing more about it because of the dissociative splitting of the associative networks. There are no symptoms, only phenomena at the level of the body and, should a consultation for these phenomena occur, it usually comes much later precisely because these patients have little inclination to approach the Other; the Other didn’t give much of an answer in the past after all…

This means that in a large number of cases the diagnosis is made considerably more difficult, not only because of the temporal gap between the accidental trauma and the disturbances, but also because the patients themselves are unable or unwilling to make the connection. Research has shown that many patients come for consultation without connecting their troubles to their sexual or physical abuse as a child (Price et al. 2001, pp. 1096–1097). This, in combination with what is sometimes even the complete absence of a demand for help, requires the diagnostician to be all the more attentive to a number of often vague indications and characteristics. We will now address these from the perspective of their underlying structure, starting with the description in the DSM-IV.

Descriptive Characteristics in Light of the Underlying Structure

PTSD is classified under the heading of anxiety disorders, but it will soon become clear that it overflows into a number of other categories as well. The DSM-IV description is as follows

309.81 Posttraumatic Stress Disorder

A. The person had been exposed to a traumatic event in which both the following were present:

(1) The person had experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

(2) The person’s response involved fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganised or agitated behaviour.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognisable content.

(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur.

(4) Intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

(5) Physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma.

(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma.

(3) Inability to recall an important aspect of the trauma.

(4) Markedly diminished interest or participation in significant activities.

(5) Feeling of detachment or estrangement from others.

(6) Restricted range of affect (e.g., unable to have loving feelings).

(7) Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by two (or more) of the following:

(1) Difficulty falling or staying asleep.

(2) Irritability or outbursts of anger.

(3) Difficulty concentrating.

(4) Hypervigilance.

(5) Exaggerated startle response.

E. Duration of the disturbance (symptoms in criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. [American Psychiatric Association 2000, pp. 467–468]

Criterion A concerns the etiology and immediately gives an indication of its complexity. It is not just a question of having experienced the trauma oneself, one may have been witness to or—even more vaguely—been confronted with it. The subject’s own reaction, moreover (Ad 2), is decisive. Here we come up against the “indirect” trauma that helps to explain why children of concentration camp victims suffer more from PTSD than their parents. This is the step toward an imagined trauma, which immediately brings us to the discussion about a trauma’s real or imagined nature, a discussion that has already reappeared several times in history. Such an indirect effect once more diminishes the importance of the factual nature of the trauma, and shifts the focus onto the subject itself. In its relation with the Other, the subject may take over the Other’s trauma through incorporation or identification, which is literally an “imagining,” an “in-imaging”¹⁰ Clearly, such an imagined trauma can have effects just as important as the actually experienced trauma.

The emphasis here is on the threat of death or injury, not necessarily on the actual injury. In cases of war trauma, Freud suggested that an actual injury may reduce the chance of developing a subsequent PTSD, but as far as I know this hypothesis has not been confirmed. Under this heading fall those forms of usually chronically traumatic situations, where the trauma is said to be merely psychic, and is therefore much more difficult to detect.

At A(2) we find the traumatic, automatic anxiety that is quite close to panic attack. At its heart is the fact that the subject is obliged to take the passive position, thus forcing it to collapse back into the original, early infantile position of helplessness where only the Other can provide the specific actions and signifiers that makes coping possible.

Intrusive Reexperiencing

Under Criterion B we find the repetition compulsion, and intrusive reexperiencing that has nothing to do with memory. The typical characteristic of trauma is precisely that it cannot be remembered through signifiers. The inscription took place on the body, in a different memory system than of declarative memory.¹¹ Consequently, there is also no return of the repressed, nor is there any psychopathological symptom construction and its resultant repetition. Instead, we find a repetition compulsion that the subject is unable to control; it is a reexperiencing followed by a defense against it, often with somatization phenomena as a result. The patient tries to grasp what was never originally psychically inscribed in the declarative memory. The so-called memories are always monolithic, unprocessable, and intrusive, always imposing themselves under the form of the same verbal fragments, flashbacks, bodily sensations.

The same goes for traumatic dreams as well, which for Freud were the sole exception to what he considered the central function of the dream, namely, to maintain sleep through wish fulfillment. Their effect, in fact, is precisely the opposite, because the dreamer is woken up by what Lacan calls a missed encounter with the Real (Lacan 1994 [1964], pp. 53–56, 68–70). The missed aspect lies in the impossibility of turning the traumatic Real into signifiers, and this is why one wakes up precisely at the moment “it” is going to happen. Such traumatic dreams often engage a vicious cycle. A secondary signal anxiety is developed against sleeping, precisely because of the nightmares, resulting in a reversal of the day and night rhythm that in turn causes further disturbances in somatic and social functioning, with serious somatization effects.

In this way, the idea of “symbolizing the traumatic event” must be interpreted and revised. Here it has nothing to do with symbolization at all, but with an automatic evocation of the trauma through triggers, provoking an uncontrollable reexperiencing. Once symbolization proper becomes possible, the psychic-associative processing of the trauma can take place, together with its (literal) re-covery.

Hypervigilance and Distrust

Criteria C and D present different elements that could be better organized. Psychologically, the inability to recall (C3) is the core problem: the traumatic experience has not been inscribed in an ordinary psychological way and therefore cannot be associatively processed. This characteristic deserves a much more central place in the diagnostic description and belongs, moreover, to Criterion B.

Under C1 and C2 we find secondary avoidance behaviors, and the entire criterion D could be included in here as well. Sleep disorders (D1) always have to do with the continued vigilance and desire to avoid traumatic dreams. D (3 to 5) needs explanation because it seemingly contains a paradox (difficulty concentrating versus hypervigilance). PTSD patients do not pay “normal” attention to the surroundings, thus giving the impression that they are not paying any attention at all. Nevertheless they are hyperconcentrated and hypervigilant, albeit with respect to (the avoidance of) reexperiencing the trauma and the desire to control the Other, or, more broadly, the surrounding environment. When such hypervigilance lasts too long, somatization phenomena occur from exhaustion. Often this leads to abuse of medication (alternating between sleeping pills and pep pills), thus creating further problems (e.g., addiction). Aggressive reactions (D2) also belong in this category, and may additionally turn into their opposite, that is, a total lack of reaction.

Immediately following from this, we can isolate a final group of characteristics (C 4 to 7), namely, the PTSD patient’s characteristic relationship with the Other. This too finds insufficient elaboration in the DSM description. The heart of the matter is that trust in the Other is missing because she or he originally failed to respond, or didn’t respond sufficiently at the moment of the structural trauma. In its place we find a distancing from or fundamental distrust of the Other. The effect is social isolation as a choice, and this takes a totally different form from the neurotic variety of loneliness and its accompanying complaints.

A final remark concerns the way the link with the preceding structural trauma—more broadly, with the premorbid personality—is not just missing in the DSM categorization, but is even rejected (“not present before the trauma”), while almost all research results have shown this link to be necessary. This absence follows from a certain naiveté: the DSM description begins with the idea that the trauma, as the cause of the disorder, is already known. In clinical practice, this is often not the case. Many referrals take place as a result of the secondary phenomena, without any knowledge of a link to a trauma. The sole finger pointing in this direction is the specification “with delayed onset.” If we were to add to this the impossibility of remembering the trauma, combined with a negative relation toward the Other—and therefore toward the clinician—it becomes clear why diagnosis here is not a simple matter.

Differential Diagnostic Difficulties and Implications for the Treatment

First and foremost, we must stress that PTSD in itself does not determine a specific structure of the subject. But this doesn’t prevent us from approaching it structurally: PTSD always goes back to the actualpathological position of the subject, where the psychopathological processing only barely took place. The specific structure of the subject (neurosis, psychosis, perversion) fully determines how it appears. Later we will discuss its most well-known manifestation, namely, the neurotic structure, better known as borderline.

In addition, what must be emphasized is how frequently PTSD is a missed diagnosis (particularly in cases of a psychotic or perverse structure), or one that is made far too late. We have already seen the reasons for this. The effects of a chronic traumatic history can be very diverse, and moreover spread their visible effects over a large number of diagnostic categories. Such effects are often so striking that they claim all of the attention. The typical example here is female alcoholism.

As clinicians, we must be aware that we are being confronted with a complex final product, thus proving once more the need for a very thorough investigation of the case history. Here, the difference between a real or imagined trauma is less important than a continued attentiveness to the relation between the subject and the Other; indeed, it is precisely the structure of this relation that will determine whether or not PTSD is developed, not the nature of the “event.”¹²

Its spillage over into other categories is evident anywhere one looks in the literature—between 60 and 90 percent of PTSD patients receive at least a double diagnosis (for a summary, see Lee and Young 2001, pp. 152–153). In fact, any referral beyond the classical psychopathological spectrum can hide a traumatic history. Classic in this respect are the affective and anxiety disorders and somatoform and dissociative disorders, together with sleep disorders, because these directly connect with actualpathological phenomena as effects of the structural trauma. The roomy catchall of what are known as adaptive disorders carries many features that refer simultaneously to PTSD, particularly if we understand these as coping mechanisms for (the effects of) the trauma by way of a passive–active reversal. With this, I am thinking of aggressive acting-out, sexual promiscuity, automutilation and suicidal behavior, and disturbances in impulse control. Addiction is ubiquitous, and even eating disorders are not uncommon.

No wonder that many are calling for a revision of the category. A well-known example is Herman’s idea of a “complex post traumatic stress disorder” (Herman 1992a) or even a DESNOS (“Disorders of Extreme Stress Not Otherwise Specified,” [Herman 1992b]). For me, this proves once more how a categorical descriptive diagnosis will inevitably fail and how one must fully attend to the underlying structure of the subject in its relation to the Other.

This latter idea is the most important conclusion for differential diagnostics. An initial diagnostic evaluation will almost always have to do with the actualpathological phenomena in the Real, along with their accompanying defensive avoidant behavior. The step toward diagnostic recognition of the importance of the relation with the Other is made only when one realizes that such phenomena always boil down to a passive–active reversal: what one passively underwent is now actively repeated in an attempt to master it, albeit beyond the realm of the signifier and therefore the Other. This brings us, finally, to the most crucial element of diagnosis. Chances are that when there is an underlying actualpathological structure that has been reactivated by an accidental trauma, the Other—and hence the clinician as well—will be warded off. The perpetual attempt to rejoin the Other notwithstanding, the Other is not to be trusted. It is even more so in cases of a preceding chronic trauma: the Other must be kept under control.

What the clinician normally expects, in other words—the attribution of a position of assistance along with the guaranteeing aspect of the position he or she occupies as the subject “supposed-to-know”—is anything but assured here. In a number of cases, she or he will meet the exact opposite, that is, a repetition of the original basic distrust. A silent, uncooperative patient with a series of vague complaints, often combined with addiction, doesn’t lend herself to a very positive attitude in the clinician. If, within a short period of time, this patient should then try to take hold of the reins, a negative countertransference is usually installed, even a rejection on the part of the therapist. The result is a repetition of the original actualpathology and, hence, a confirmation of the problem: the Other takes off, the subject is left alone.

This is all the more debilitating because the central aim of the treatment here is the creation of a therapeutic relation that will enable the patients to take the active position. This latter is not so much oriented toward action but toward an active mastery of the Real through language that simultaneously allows the subject to acquire a new layer of identity. Any approach that maintains or even puts the patient in the role of passive victim merely reconfirms the original structure.

As far as treatment is concerned, it has become clear in the meantime that a classic psychoanalytic approach, directed toward the analysis of symptoms through interpreting the underlying conflict, doesn’t work. Indeed, because of the actualpathological position of the subject, there are no symptoms. In their place, the emphasis must be on the installation of an effective therapeutic relation, through which subject amplification can occur. This is nothing but the redoing of the original process of subject-formation, through which the subject acquires the signifiers necessary for processing the Real of the body. In this respect, it is not so much a question of presenting the patient with the “correct” signifiers as of creating a relationship in and through which these signifiers can be taken in and assumed from a guaranteeing Other.

Much the same line of reasoning can be found in the development of cognitive behavioral therapy. In place of the earlier systematic desensitization and flooding, now the emphasis is on the “imaginal exposure.” As far as I can see, this comes down to an installation of a secondary processing in and through the presence of a security-providing Other, in which it is frequently the therapist who, as the Other, repeatedly puts the traumatic experience into detailed words: “Imaginal exposure involves the trauma survivor or the therapist narrating repeatedly the traumatic experience in detail” (Livanou 2001, p. 181; my italics). Everything is then taped so the patient can listen to it again at home. What is insufficiently stressed in this approach is the underlying structural ground and the need to construct an effective relationship as such. It is precisely the failure or the success of this that will determine the therapeutic outcome.

All this is even more true for a clinical category that is (in)famous for the difficulties it presents in the transference. I mean the so-called borderline disorders, whose interrelation with PTSD is seen almost everywhere today. This will be our next topic.

BORDERLINE DISORDERS: THE ACTUALPATHOLOGICAL POSITION IN THE NEUROTIC STRUCTURE

In today’s hit parade of personality disorders, borderline personality disorder (BPD) tops the list. What has recently become increasingly clear is that it is connected with PTSD. First, on a purely phenomenological level, it is easy to see an analogy—it suffices just to compare the DSM descriptions of PTSD and BPD (Herman 1992b). Furthermore, in a large number of empirical studies a trauma is discovered at the base of BPD.

At first sight, this might seem to indicate that BPD could be interpreted as if it were a special case of PTSD. To me, this doesn’t seem like a fruitful line of reasoning. So-called PTSD, as described above, comes down to the purely phenomenological summary of the effects following an accidental trauma in someone with a prior existing actualpathological structure. The latter, in any case, is the necessary condition for PTSD phenomena to develop. The implication is that PTSD is not in itself determining for any specific subjective structure, but can occur just as easily within a neurotic, a perverse, or a psychotic structure.

Since it is based on observation, the DSM category is unable to take this into account and, hence, doesn’t allow one to make a structural diagnosis. The discussion above described in general terms the interaction between an actualpathological position and the retroactive effect of an accidental trauma. “General” here implies that it can be recognized in the three subject structures, with the proviso that each structure will determine a number of specific characteristics. We will shortly examine this in relation to the perverse structure. This, too, can be approached from the actualpathological side of the continuum.

My argument is that what we understand as BPD today amounts to an actualpathological position of the neurotic relation between the subject and the Other. Remember: it involves a neurotic subject who, in its initial confrontation with drive arousal, received neither the Other’s signifiers—or not enough of them—nor the Other’s guarantee, needed to set the secondary processing in motion and to make the step toward the psychopathological side of things. I am following Jonckheere (1993) here, although his emphasis was on the anxiety neurosis.

With this, I distance myself from the original conception of borderline, which located it between psychosis and neurosis (Kernberg 1975).¹³ Instead, I see the classical borderline as situated between the actualpathological and the psychopathological position of the neurotic structure, albeit with a very clear shift toward the actualpathological side. It is precisely an unfamiliarity with Freud’s original differential diagnostics that lies at the bottom of the classic idea that locates BPD between neurosis and psychosis. The same logic can be applied to the perverse and psychotic structures. There too we can make a diagnosis based on the subject’s position in the continuum from actualpathological to psychopathological positions.¹⁴ Anticipating what follows, I can already list a number of well-known clinical characteristics of BPD that prove my point. The chief argument for understanding classical borderline as pertaining to the neurotic structure has to do with the presence of so-called reality-testing. For me, this means that the oedipal triangularization has been carried through and that the dual-Imaginary functioning has been superseded by the Symbolic. Thus it doesn’t so much concern reality-testing as a sense of symbolically determined and shared reality. This is not so in the psychotic structure that remains glued, as it were, to the Real (see Chapter 15). The implication is that BPD pertains to the neurotic structure.

The actualpathological character of BPD is illustrated by two well-known clinical facts (Vermote 2000). For the borderline patient, the emphasis is on the present, in the therapeutic interaction as well. From here it follows that the patient expects concrete proof of the therapist’s commitment, if not to say his or her “love.” The connection with the original relationship between mother and child, where the child required a “specific action” (Freud) from the mother, is clear. The same idea appears in what Vermote (2000, p. 669) calls the third and fourth directions taken in the psychoanalytic conceptualization of BPD, despite the fact that the authors he cites fail to make this connection with Freud’s actualpathology.

In the third movement (Winnicott, Balint, Kohut, Bion), the focus is on the failure of the basic experience between the mother and child, be it based on a trauma or on not “good enough mothering.” Instead of the necessary “holding environment” (Winnicott), “primary love” (Balint), “primary empathy” (Kohut), or “containment” (Bion), a “basic fault” (Balint) appears, a “primitive agony” (Winnicott), a “fear of fragmentation” (Kohut) or a “nameless dread” (Bion). The latter expression expresses best what is involved here: the structural trauma of the drive is not (or is insufficiently) represented by a guaranteeing Other; the confrontation with the nameless drive keeps on insisting. Fear of fragmentation can easily be understood as a failure in the mirror stage, making it impossible to install the bodily image as a totality.

The fourth direction (Fonagy, Target, Bateman) is characterized by an emphasis on the Other, more specifically, on his or her failure, and its effects. In the language of contemporary attachment theory, this failure of the Other implies that the subject will not be able to “mentalize,” that is to say, to regulate the drive through internal representations and constructions about the subject’s identity and the identity of the Other. Instead, projective identifications are installed, along with an immediate abreaction of the drive arousal in the present, whether on the other, or on the subject’s body.

It is largely from this last approach that my discussion of BPD will begin because it is closest to my own Freudo-Lacanian approach to subject-formation. It is true that little attention has been paid to BPD from a strictly Lacanian perspective (Jonckheere 1993). I will begin not with the narrow DSM definition but with today’s broader understanding of it. The indicative characteristics are: dramatic regression, psychotic-like episodes, intense (counter)transference and acting out.¹⁵ The most recent rundown goes like this (Fonagy et al. 2002, p. 346):

• Disorganized and dysfunctional self-organization and consequent problems in affect regulation and emotional self-control (including feelings of emptiness, lack of a stable sense of self, emotional instability, and impulsivity);

• Dysfunctional and distorting “social-reality-testing” abilities: the dominance of defensive modes of functioning in intimate relationships, and in the analytic transference characterized by splitting and projective identification;

• Vulnerability to trauma, serious difficulties in maintaining intimate attachment relations, proneness to provoke abandonment, and consequent suicidality.

In what follows, I will work through these descriptive characteristics from a structural point of view, focusing on identity formation.

BPD and Subject-formation: Projective Identification, Splitting, Enactment

In normal subject-formation, the mirror stage provides the first layer of identity through which the partial drives are taken up in the total body image and their first regulation is installed. As I showed in Part II (Chapters 6 and 8), this is first of all a dual functioning without any distinction between the subject and the Other. The Oedipal structure introduces a third point and, hence, difference, making symbolic distancing and further representational processing possible. As a result, three things develop at the same time: symbolization, the human reality it determines, and the subject itself.

In cases of BPD, the original mirroring process takes a different course. The child doesn’t receive a guaranteeing S₁-signifier from the Other for processing its (a). Instead, the child is confronted with a mirroring that gives it no way of handling its drive. Patrick et al. (1994) and Fonagy et al. (1996 and 2002) discovered a high correlation between the BPD-diagnosis and a preoccupied attachment style, concluding that the traumatic experiences remained unresolved and there is a striking reduction in reflective capability.

The effect of such an attachment style must be understood within the broader theory of attachment; focusing purely on the attachment style itself is not enough (Fonagy et al. 2002, pp. 344, 349 ff; and see Chapter 6). In attachment theory, development is described in this way: the internalizations of the representations of the “internal states” (what I have been calling the primal alienation through which (a) is introduced into representations) depends on a sensitive mirroring by the caregiver (the first and second Other). On this basis, a teleological model of the mind is initially developed in the child, being a combination of the representation of the self-experience and the representation of the reactions by the caregiver. This model enables the child to interpret both its own drive and the Other.

The next step in development is that from a teleological to an intentional position. This depends on how much security the child experiences in its exploration of the caregiver’s mind, that is to say, it depends on the nature of the attachment. In a secure attachment, a safe exploration of the other becomes possible. In avoidant attachments, the mental state of the other is avoided. In resistant attachments, a focus on one’s own “distress” follows, which excludes intersubjective interactions. Finally, in disorganized attachments, there is a hypervigilance toward the other, but without any positive consequence for self-organization—such children are immensely capable of reading the other’s mind, but cannot read their own.¹⁶ The final step in normal development takes place through the oedipal triangle and implies a stepping away from the equivalence between internal and external reality to a mentalized internal world, through which subjective experiences are recognized as just a single version of the external world, being a “representation of reality.”

Empirical research has repeatedly shown the presence of a preoccupied attachment in combination with the unresolved character of early traumas in adult BPD patients. Consequently, there is no differentiation between external and internal “reality,” by which we must understand that there is no differentiation between the subject’s identity and the identity of the Other. The first alienation comes down to an identification with emptiness or with a rejecting Other. Therefore, no secure basic identity is developed, no “authentic, organic self-image built around internalized representations of self-states” (Fonagy and Target 2000, p. 864).¹⁷ This has a number of typical consequences. A chaotic sense of self or even an inner emptiness is installed as far as identity is concerned, a void combined with anxiety. Normal affect regulation and control are absent because self-regulation through the Other’s normalizing signifiers has not been established. Next, this gives rise to a craving for identity and a propensity to drink in the meaning-providing signifiers of the Other through physical proximity-seeking, albeit in combination with psychological avoidance as a result of the primary rejection by the Other. No coherence or synthesis gets developed at the level of identity.

Psychological functioning continues to operate in the equivalence mode, the dual-Imaginary, with a reversibility between the subject and the Other. Little Symbolic distance-taking or reflective functioning is possible, and the secondary processing or mentalizing (Lecours and Bouchard 1997) fails to develop. Here, an important differential diagnostic criterion must not be missed: the sense of reality, as determined by the symbolic order, comes into being in a thinglike way. What fails to be installed is a sense of social reality; at that level the psyche remains stuck in a dualistic mode. Whatever is thought in relation to the other and his or her intentions, is experienced as monolithic, real and actual. “Monolithic” and “real” mean that there can be none of the nuances of distance taking; “actual” means that no associative link to the subject’s history can be found. In brief, there is no integration of the equivalence and the pretend modes (Fonagy and Target 2000, p. 855; and see Chapter 6).

In daily life, this may lead to a hyperalertness that attachment theory calls “hypermentalization”: the patient has an excessive though selective awareness for detecting psychic states and intentions in the Other, and reacts to them in a black-and-white manner. This is translated into the need for the other’s physical presence as well, albeit always in combination with an anxiety about this presence—this is the need for a physically present “mirror” that enables one to know what one is actually feeling by way of the other’s gaze. One step further and such a demand for physical presence gives rise to acting-out, whether sexually, aggressively, or—frequently enough—a combination of the two. Throughout this entire functioning, thought and reality concerning the other, the relation and the subject’s own identity remain synonymous; moreover, the reversibility between the subject and the Other is maintained. As a result, the clinician encounters the characteristic division of the subject (splitting), the characteristic mechanism of defense (projective identification), and the typical BPD proneness for action (enactment).

The subject will then process its drive by sending out what is experienced as the bad or dangerous part to the outside and unilaterally situating it in the Other. Rather than the integration of alienation (the taking in) and separation (the distance taking), we come up against a projective identification (Ogden 1979). This implies that the unmanageable drive is unilaterally projected onto the Other and treated defensively there. The nature of projective identification is such that the other becomes reduced to it and seems to be left with only two possibilities: she or he can either behave in that way, or pull out entirely.

The intent of such projective identification is defensive in two ways: the drive (a) can be controlled by sending it outside and, by the same token, the other can be controlled as well. The latter can take two forms, presumably mirroring what the borderline patient originally experienced from the mother and/or the father: aggressive punishment or overconcern. This has been demonstrated in young children with a “disoriented/disorganized” attachment, from ages 5 to 7 onward (Main and Cassidy 1988; Solomon et al. 1995).

As a result, the construction of social reality and interpersonal relations runs in tandem with subject-formation, that is, in terms of black-and-white, and the latter will be called “splitting.” Its difference from normal subject division boils down to the fact that the separate identificatory layers remain distinct and are unintegrated. The “inner” and the “outer,” the subject and the Other remain both separated and reversible. Hence the typical adult interpersonal relations: it is always either everything or nothing, either extremely positive and intimate, or extremely negative and rejecting. There can be no nuancing through the reflective function. Hence the rigidity of interpersonal relations; the dual mode of functioning allows no distance taking; normal reflectivity is absent. Beyond the black-and-white pattern of relations, the borderline subject faces an inner emptiness (i.e., the lack of a primal identification) and its accompanying feeling of disorganization.

The link with dissociation in PTSD is clear. On the basis of two prospective longitudinal studies in adolescents, one can make a correlation between one of the most important PTSD symptoms, that is, dissociative phenomena, and disorganized attachment (Carlson 1998; Ogawa et al. 1997), and, therefore, to borderline pathology. Nevertheless, what is called splitting goes much further than the dissociative reexperiencing of unrepresentable trauma. It is used to deal not merely with the isolated, intrusive reexperiencing of traumatic elements, but with identity per se.

In addition to splitting and projective identification, the persistence of dual functioning—where thoughts and reality regarding social interactions are synonymous—has still another consequence. The equation between thought and reality gives rise to a quasi-immediate putting into action of what is thought, known as “enactment.”¹⁸ Classically, this can take two directions: an aggressive and/or sexual attack or seduction, each time in an unveiled manner. The sexual aspect can at first sight give the impression of an easy-going, unfrustrated attitude, but a closer look reveals that a proper intimate relationship is very difficult and is even experienced by this subject as threatening. The borderline patient has great difficulties acknowledging the other in its otherness; she or he cannot internally imagine or remember what the other thinks or desires. Because of projective identification, the other is completely colored by the drive arousal that must be warded off.

Interpersonal relations then become profoundly equivocal: an intense separation anxiety is combined with an accompanying need for physical presence, yet it is almost impossible to enter into intimate psychological relations. The other may not come too close and must, above all, be kept under control. This latter brings us to the often-mentioned traumatic etiology of the borderline pathology.

Relation to Trauma

Over the past decade, empirical evidence for the relation between borderline pathology and infantile sexual abuse has been steadily appearing (Herman 1992b; Johnson et al. 1999; Paris et al. 1993). In itself this is not an explanation, far from it. As argued above, trauma alone is not sufficient as an etiological ground for a later pathological disturbance. This obliges us to reconsider the idea of trauma once more. My argument is that borderline pathology does indeed go back to trauma, but to an early infantile traumatic relationship toward the Other, through which mentalization and reflective functioning fail to arrive at a normal development; sexual abuse is the most well-known variety of such a traumatic relationship, but the latter can take more subtle and less visible forms as well.

Recent research has focused on the relation between reflective functioning and borderline. The clear result was that BPD patients scored very low on reflective functioning, and that in more than 80 percent of the cases there had been sexual abuse during childhood (Fonagy and Target 1996a). In an inverse study, the starting point was a group of patients whose sexual abuse as children was already known. In this group it was possible to isolate a subgroup that met the diagnostic criteria for BPD, and it was precisely this group that had very low reflective functioning (Fonagy et al. 1996). Consequently, the conclusion is that not everyone who experiences sexual abuse develops BPD, and that those who do have low reflective functioning abilities.

Actual trauma in itself, therefore, is not the direct cause of borderline disorder. Its etiology lies in the fact that this trauma occurs in an early child–Other interaction that doesn’t permit the development of secondary processing and the fundamental fantasy. This has to do with the failure of the Other’s guaranteeing function, the failure of “parental mirroring.” The grounds for this failure can either be constitutional and/or traumatic and/or a psychopathology in the parents. With regard to the latter, depression in the mother is a well-known factor (Murray and Cooper 1997). Fonagy and Target (2000) observe that the core etiology has to do with a certain parental inability to imagine themselves in the child; and such a situation can also arise without a clear parental pathology or actual trauma (Fonagy et al. 2002). The psychoanalytic understanding of the effect of trauma is thus confirmed: the impossibility of representing the internal drive arousal and the absence of the representational processing of separation (see Chapter 6).

Should real abuse be present, the first alienation and mirroring occurs with a traumatizing Other. As a first result, the first layer of one’s “own” identity is only narrowly related to the drive arousal (a), but is instead related to the Other’s drive; thus, there is no representation of nor knowledge about one’s own drive. The second consequence is that this identity is threatening for the subject, because it contains persecution and abuse. Hence the ever-present risk of masochistic behavior and the self-provocation of new abuse.

Indeed, where the previously mentioned hypermentalization takes place in a history of sexual abuse, this can have unfortunate consequences. The patient him- or herself actively seeks new abusers so as in this way to regulate its own drive, as well as to build some kind of identity, albeit through identification with the aggressor. The patient looks for “abusers, who, through maltreating her, helped her temporarily to reduce her unbearable sense of diffused identity” (Fonagy and Target 2000, p. 868). In contrast, tender intimacy is dreaded. The trauma is thus repeated and the traumatic relationship toward the Other maintained.

Implications for Differential Diagnostics and Treatment

Let us resume from our initial thesis. The classic borderline patient pertains to the neurotic structure, more specifically to a level of neurotic structure that has only barely left the actualpathological position. In this sense, there is no development of the fundamental fantasy, nor is there any secondary processing through triangular structuration. The defensive processing is limited to actualpathological phenomena and there are no Symbolico-Imaginary symptoms properly speaking. As far as the position toward the Other is concerned, that is, toward language and the other, dual-Imaginary functioning predominates, characterized by reversibility and the inseparability of thought and reality with regard to social relations. Hence the rigid, black-and-white nature of the exchanges. The relation between the subject and the Other remains within the dual-Imaginary (the “splitting”) and is mainly experienced through unmeditated projective identification and enactment. Processing by way of the symbolic phallus, as the opening between the subject and the first and second Others, doesn’t occur.

In place of such processing, we find actualpathological phenomena, with their inevitable focus on the body. Again, this indicates an underlying process, or rather the failure to introduce the drive tension into the representational order. The most well-known examples of this in borderline are automutilation and addiction. Both are direct attempts at coping with the arousal of the organism to control the drive.

Addiction, to both legal and illegal products, is not hard to understand. It is a pseudomedical practice, which Loose aptly calls “administration” (Loose 2002). The addictive product is used as a “floodgate” for controlling the subject’s jouissance, resulting in the creation of a new problem, addiction.

Automutilation is also fairly well-known in the borderline pathology (Fonagy et al. 1993; Fonagy and Target 1995). It must be understood within the larger context of the ever-present tendency toward impulsiveness and enactment in view of the reversibility between thought and action. Moreover, the “auto” is also relative, again in light of the reversibility of the subject and the Other. Aggression can go in both directions here. In contrast to anorexia-bulimia, the emphasis is not on the refusal of the relationship with the other (see Chapter 8), but on the relationship between the subject and (a). When one can get these patients to talk about their automutilation—something that is far from easy—one usually gets a variation of the following: they experience an ever-growing internal tension that provokes more and more anxiety—anxiety about disappearing, exploding, becoming completely mad. The cutting or burning occurs at the moment the climax becomes almost unbearable, and always has a tension-reducing effect—order returns. The defensive processing through the Other is almost entirely absent here—hence the inherent difficulty for these patients of talking about it; the processing is instead real and unmediated.¹⁹

From a differential diagnostic perspective, the relationship the borderline patient establishes, both inside and outside the consultation room, is of decisive importance. The proximity of the Other is at once both sought—as an answer to (a)—and avoided. Both the subject’s and the Other’s fantasies are experienced as real and therefore dangerous—the dual-functioning mode does not allow any distance taking. Moreover, projective identification imposes the subject’s drive onto the other in such a way that the other becomes reduced to it.²⁰ Because of the actualpathological position, drive regulation and a coherent identity are missing—hence the instability of every relationship, together with an intense impulsiveness. Out of the lack of sufficient symbolization, the step toward action takes place very rapidly, something that is also demanded from the other. The instability of the relation doesn’t prevent there from being a patent rigidity, in the sense that psychic reality and objective reality are regarded as identical. Their contents can rapidly revert to the opposite, hence the instability. This, in turn, gives rise to splitting, both in the subject’s identity and in the identity of the other.²¹

Like the characteristic borderline phenomena, the nature of the relation can be understood from the perspective of actualpathology. The maintenance of the sense of reality and of the desire to connect to the Other, moreover, indicate the presence of a neurotic structure. It is in this sense that I regard classical borderline as the actualpathological position of the neurotic structure, alongside anxiety neurosis and actualpathology.

Differential diagnosis with psychosis has become more difficult with the ever-increasing expansion of research into both psychosis and borderline pathology. Once we limit ourselves to the classical borderline definition, however, it becomes less problematic. The psychotic subject has no sense of reality. Particularly during the acute episode, words and things are synonymous, and reflective functioning is absent entirely (see Chapter 15). On the other hand, while the borderline patient has no sense of social reality, the objective side of symbolically determined reality presents him or her with few difficulties. The differential diagnosis with psychosis becomes a lot easier, moreover, when one assumes that the actualpathological position can occur in the psychotic structure as well.

As far as perversion is concerned, the differential diagnosis becomes simultaneously both simpler and more problematic. The simplicity has to do with the predominance of the juridical diagnostic system that today stresses the transgressive behavior in perversion. But from a clinical perspective a number of things become a lot more complex. “Splitting” can be found in perversion, too, as well as an emphasis on enactment. The chief difference has to do with the specific mechanism of defense (disavowal) and the relation toward the first and second Others (see Chapter 14).

Therapeutic Consequences

To conclude, let us examine the therapeutic consequences of the relationship with regard to the borderline patient. As this pathology leans toward the actualpathological position, psychoanalytic treatment in a classical sense is difficult, if not impossible. Symptoms, in the classical meaning of the word, are barely present. An analysis of the transference based on the case history of subject-formation is very tricky because of the ahistorical character of the actualpathological position. In this sense, the mere possibility of a transference analysis can already be considered a positive result of the treatment.

Interpretation, in the Freudian sense, has neither effect nor ground—indeed, there is scarcely any secondary processing present, because the development of significations in the Imaginary failed (see Fonagy and Target 2000). Rather, the treatment will have to focus on creating the possibility for developing a secondary elaboration, the a → . The anxiety, as a reaction to the incomprehensibility of the drive, appears in its primary form and the subject literally has not “come to terms” with it. Indeed, no adequate representation was developed for it. Therapy must provide a new beginning through the therapeutic relationship, understood as a largely supportive and name-giving relationship with a security-providing Other. This implies that a significant number of the interventions have to be focused on the here and now so as to enable one to establish a later and an elsewhere, that is to say, an ability to take symbolic distance and to cope.

In a positive working alliance, the secondary elaboration can be stimulated, with the emphasis on a growing amendment of the image of the self and the Other. In a negative working alliance, the therapist must be able to contain the negative image so as to make it clear through the treatment that other options are possible. The effective goal, then, is the enlargement of the secondary elaboration and the accompanying reflective functioning.

This sounds easy. In reality it is anything but. The transferential relationship is very difficult to manage. Because of the actualpathological position, there is barely any coherent sense of identity, and it is precisely this that causes a very strong physical separation anxiety. Without the actual presence of another, the borderline patient does not exist. The inner image of the self is empty, the other is vital as the constant mirror in which patients confirm their existence. The ensuing appeal to the therapist can take on a very demanding, even compelling nature. Another outcome is the high risk of suicide, which is almost always triggered by what the patient has experienced as separation. Furthermore, the aggression can go in two directions: toward the patient him- or herself or toward the other. Freud’s original theory that in a number of cases murder can be regarded as a disguised form of suicide, is illustrated by this (Fonagy and Target 2000, pp. 965–869). “Lighter” versions are physical aggression toward the subject’s own body (automutilation, addiction) or toward the body of the other.

In the same strain, we encounter the effects of projective identification and enactment. There is a huge difference between this and the normal-neurotic transference where the therapist is always staged in an Imaginary scenario to which he or she can react fairly easily with the requisite abstinence. The borderline patient skips over the imaginarization and thereby comes much closer to the Real, and frequently enough to what functions in Lacanian discourse theory in the position of the truth. Time and again, the borderline patient performs miracles in the provocation of heated (counter)-transferential reactions, getting under the therapist’s skin. The next step to “enactment” on the therapist’s part is not all that rare.

1. As we saw in the first part, an analogy can be made between the genetic answer and the naive trauma model; in both cases the cause is defined as external to the subject, and we find ourselves back in the victim model. As we will see later, this is the worst possible approach to take for PTSD patients because the treatment thus confirms them in their passive position.

2. Freud, too, discovered that trauma has a particularly traumatic impact when repeated. As I stated at the beginning of this chapter, the contemporary hype around PTSD is a return to the clinic’s historical starting point. Hence we can predict the sequel: after an initial focus on the real character of the trauma and the role of the victim (“survivors” in newspeak) it will shift more and more to the personality factors of the patients themselves, making the initially easy diagnosis increasingly hard and raising a number of “new” questions. History will repeat itself, particularly when we ignore it.

3. This enables us to give an operational definition of trauma: it is an impact on the subject by a part of the Real that cannot be put into signifiers. Such an operational definition is needed to distinguish between emotionally shattering events and trauma. Lacan talks about a “trou-matisme” (1973–1974, lesson of February 19, 1974; Translator’s Note: Lacan is making a play here on the French word for gap (“trou”) and traumatism (“traumatisme”); see Freud’s definition: “We apply the term “traumatic” to an experience which within a short period of time presents the mind with an increase of stimulus too powerful to be dealt with or worked off in the normal way, and this must result in permanent disturbance of the manner in which the energy operates” (1978 [1916–1917], SE 16, p. 275). The connection with the drive excitation is clear, and Freud will also describe the confrontation with the drive as a confrontation with a rise in tension that must be psychically processed (Freud 1978 [1905d], SE 7, p. 168). See also his description of the primary repression as the first defense against the drive (see Chapter 7 of this book).

4. We often hear these days about “bottomless children” but it is not exactly clear what “bottom” or baseline they are missing. From our perspective, this baseline concerns that primary relationship in and through which the Other presents the child with the signifiers it needs to enter the world, including the world of its own drives.

5. Translator’s Note: The Dutch verb to remember, “te herinneren” literally means “to bring back inside,” to re-internalize.

6. “Emotions are stored in memory networks that contain information about stimuli, responses, and meanings related to emotional events. Retrieval occurs when external or internal cues result in ‘spreading activation’ along associative linkages to memory structures representing past events” (Bower and Sivers 1998). “Adapting this theory to PTSD, Foa et al. (1989) proposed that following a traumatic event, a fear network that stores information about sources of threat is formed,”…and so on. (Salmon and Bryant 2002, p. 168).

7. This idea of the requirement of a double trauma for PTSD to develop, where the effect of the second trauma builds on the first, can be found in Freud from the outset. Freud will later extend this line of reasoning: adult defense, fantasy, and the function of the father are grounded in a primary form and acquire their respective weight from it (see Verhaeghe 1999b, pp. 33–35 and 149–203).

8. A patient who was anally and genitally abused by her father at a very young age described it thus: “Henrietta recalls initially welcoming his attention (even encouraging it) and gradually, when ‘the pain’ started, going blank, which helped him to get inside her. She describes imagining herself as one of her dolls. This meant that she blocked any awareness of thoughts and feelings in herself or the other” (Fonagy and Target 2000, p. 866).

9. Traumatized children need the Other even more than normal children, albeit with a characteristic ambiguity because the primary need for a securing Other was not fulfilled. This is why abused children often hide the abuse from the external world—usually they are very much aware of the consequences of discovery, consequences that always come down to separation. This is precisely what is unbearable for them, because they have never lived through normal separation and still need the Other. This explains the frequently paradoxical bond between the child and the abuser, which appears very strange from outside and often leads to accusations of complicity in the child.

10. Translator’s Note: In Dutch, “inbeelding” means literally to make or bring images inside.

11. Contemporary neuropsychology has shown the existence of at least two different memory systems. The conscious, declarative memory functions through the hippocampus, while the unconscious memory operates through a system based on the amygdala. Both are operative at the same time, independently of each other. Bridges between them are indirect (LeDoux 1998, pp. 239–252). This is a further reason—in addition to the traumatizing effect of imagined trauma—why it is so difficult to make a distinction between a real and an imagined trauma. The implication is that the traumatized patient will never be able to remember the trauma in any normal way. Freud rapidly and intuitively understood this, long before contemporary neurology and any discussion of “repressed” and “false memories.” Already in 1896, he asked whether it is correct to say that the vanished memories of the trauma have really disappeared, or rather if it is the case that the therapist is confronted here with a cognitive process that never took place, meaning that the treatment has to enable the patient to perform a psychic operation that she or he was unable to carry out at the time of the trauma itself (Freud and Breuer 1978 [1895d], SE 2, p. 300).

12. In cases of a hysterical structure, with its typical susceptibility to suggestion, there is a high risk that the therapist’s suggestions concerning traumatic antecedents may be taken on by the patient, resulting indeed in false memory syndrome (cf infra). Once again, the diagnostic attention must be on the relation between the subject and the Other because it is the hysterical tendency to identify with the words of the other that makes such false memories possible. In PTSD and the underlying actualpathological position, this will be absent. A rule of thumb here (with all the obligatory restrictions concerning such rules) could be the following: When the etiology lies in the Real, the phenomena it causes will also occur in the Real; if the etiology lies in the Symbolico-Imaginary, the symptoms will belong to that field.

13. Kernberg, whose original concept it was, later extended it to all the DSM-IV personality disorders except obsessive-compulsive personality disorder (Kernberg 1996a; see also Vermote and Auwerkerken 1999). From my perspective, actualpathology may indeed be present in every subject structure. In this chapter, we will focus on “classical” borderline, that is, its neurotic form.

14. This is not just a question of changing the wording. By applying Freud’s structural distinction between actual- and psychopathology to the three possible relations between the subject and the Other, one can make a much better diagnosis with regard to treatment. Today’s vague and generalized interpretation of the BPD category is not very helpful here.

15. There are many different descriptions of diagnostic criteria, mostly relying on Kernberg (for a summary, see Verhaeghe 1993). Kernberg’s structural analysis possesses the following characteristics: “1. Nonspecific Manifestations of Ego Weakness (a. lack of anxiety tolerance; b. lack of impulse control; c. lack of developed sublimatory channels). 2. Shift Toward Primary-Process Thinking. 3. Specific Defensive Operations at the Level of Borderline Personality Organization (a. splitting; b. primitive idealization; c. early forms of projection and especially projective identification; d. denial; e. omnipotence and devaluation). 4. Pathology of Internalized Object Relationships” (Kernberg 1975, pp. 8–40). His criteria for the differential diagnostics for Borderline Personality Organization are: “1. The presence of identity diffusion (that is, of a lack of integration of the concepts of the self and of significant others, in other words, of self- and object-representations). 2. The predominance of a constellation of primitive defensive operations centering around splitting. 3. The maintenance of reality testing” (Kernberg 1979).

16. For utter clarity: children’s attachment styles (secure; anxious/avoidant; anxious/resistant; disorganised/disoriented) do not perfectly coincide with those of adults (secure/autonomous; dismissing; preoccupied; unresolved) although there is a clear correlation.

17. “Authentic” is misleading here, because throughout the whole book these authors show how this primary “authentic” self-image does indeed come from the other, that is, through his or her reactions to and interpretations of the child’s drive arousal (i.e., the “organic”). This gives rise to an inner representation in which the internal drive arousal and its external interpretation by the Other form a mirror-subject or “identity.”

18. It is not difficult to make a comparison with neurotic acting-out. The neurotic subject begins acting out when the representational elaboration (the symptom as a Symbolico-Imaginary construct) no longer functions; in that sense, neurotic acting-out indicates a border. In case of borderline, the same border is much closer, precisely because of the absence of the representational processing of the drive.

19. Like anorexia, automutilation has been recuperated by normal hysteria in the shape of piercing and its related forms. The main difference from primary automutilation is that the hysterical form is a very explicit appeal to the Other, it must be “shown” in a provocative way. Actualpathological automutilation—usually going back to a traumatic history—eliminates the Other; the patient acts on his or her own. The reversal from passive to active positions is quite clear here.

20. “Not being able to feel themselves from within, they are forced to experience the self from without” (Fonagy 2001, p.178).

21. The distinction between the first Other (the mother) and the second Other (the father) is absent from this description of the borderline’s characteristic relationship with the Other. Very little attention has been paid to the father in the Anglo-American formulation. The focus is almost entirely on the mother. This is probably an artifact of the theory. On the other hand, to the extent that it belongs to the actualpathological position, the borderline will relate to a nondifferentiated Other. Clearly further research is needed here.