Yet, despite its prevalence, BPD remains relatively unknown to the general public. Ask the man on the street about anxiety, depression, or alcoholism, and he would probably be able to provide a sketchy, if not technically accurate, description of the illness. Ask him to define Borderline Personality Disorder, and he would probably give you a blank stare. Ask an experienced mental health clinician about the disorder, on the other hand, and you will get a much different response. She will sigh deeply and exclaim that of all the psychiatric patients, borderlines are the most difficult, the most dreaded, and the most to be avoided—more than schizophrenics, more than alcoholics, more than any other patient. For more than a decade, BPD has been lurking as a kind of “Third World” of mental illness—indistinct, massive, and vaguely threatening.

BPD has been underrecognized partly because the diagnosis is still relatively new. For years, “borderline” was used as a catchall category for patients who did not fit more established diagnoses. People described as “borderline” seemed more ill than neurotics (who experience severe anxiety secondary to emotional conflict), yet less ill than psychotics (whose detachment from reality makes normal functioning impossible).

The disorder also coexists with, and borders on, other mental illnesses: depression, anxiety, bipolar (manic-depressive) disorder, schizophrenia, somatization disorder (hypochondriasis), dissociative identity disorder (multiple personality), attention deficit/ hyperactivity disorder (ADHD), post-traumatic stress disorder, alcoholism, drug abuse (including nicotine dependence), eating disorders, phobias, obsessive-compulsive disorder, hysteria, sociopathy, and other personality disorders.

Though the term borderline was first coined in the 1930s, the condition was not clearly defined until the 1970s. For years, psychiatrists could not seem to agree on the separate existence of the syndrome, much less on the specific symptoms necessary for diagnosis. But as more and more people began to seek therapy for a unique set of life problems, the parameters of the disorder crystallized. In 1980, the diagnosis of Borderline Personality Disorder was first defined in the American Psychiatric Association’s third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the diagnostic “bible” of the psychiatric profession. Since then, several revisions of the DSM have been produced, the most recent being DSM-IV-TR, published in 2000. Though various schools within psychiatry still quarrel over the exact nature, causes, and treatment of BPD, the disorder is officially recognized as a major mental health problem in America today. Indeed, BPD patients consume a greater percentage of mental health services than those with just about any other diagnosis.⁵^,⁶ Additionally, studies corroborate that about 90 percent of patients with the BPD diagnosis also share at least one other major psychiatric diagnosis.⁷^,⁸

In many ways, the borderline syndrome has been to psychiatry what the virus is to general medicine: an inexact term for a vague but pernicious illness that is frustrating to treat, difficult to define, and impossible for the doctor to explain adequately to his patient.

Demographic Borders

Who are the borderline people one meets in everyday life?

She is Carol, a friend since grade school. Over a minor slight, she accuses you of stabbing her in the back and tells you that you were really never her friend at all. Weeks or months later, Carol calls back, congenial and blasé, as if nothing had happened between you.

He is Bob, a boss in your office. One day, Bob bestows glowing praise on your efforts in a routine assignment; another day, he berates you for an insignificant error. At times he is reserved and distant; other times he is suddenly and uproariously “one of the boys.”

She is Arlene, your son’s girlfriend. One week, she is the picture of preppy; the next, she is the epitome of punk. She breaks up with your son one night, only to return hours later, pledging endless devotion.

He is Brett, your next-door neighbor. Unable to come to grips with his collapsing marriage, he denies his wife’s obvious unfaithfulness in one breath, and then takes complete blame for it in the next. He clings desperately to his family, caroming from guilt and self-loathing to raging attacks on his wife and children who have so “unfairly” accused him.

If the people in these short profiles seem inconsistent, it should not be surprising—inconsistency is the hallmark of BPD. Unable to tolerate paradox, borderlines are walking paradoxes, human catch-22s. Their inconstancy is a major reason why the mental health profession has had such difficulty defining a uniform set of criteria for the illness.

If these people seem all too familiar, this also should not be surprising. The chances are good that you have a spouse, relative, close friend, or coworker who is borderline. Perhaps you know a little bit about BPD or recognize borderline characteristics within yourself.

Though it is difficult to get a firm grasp on the figures, mental health professionals generally agree that the number of borderlines in the general population is growing—and at a rapid pace—though some observers claim that it is the therapists’ awareness of the disorder that is growing rather than the number of borderlines.

Is borderline personality really a modern-day “plague,” or is merely the diagnostic label borderline new? In any event, the disorder has provided new insight into the psychological framework of several related conditions. Numerous studies have linked BPD with anorexia, bulimia, ADHD, drug addiction, and teenage suicide—all of which have increased alarmingly over the last decade. Some studies have uncovered BPD in almost 50 percent of all patients admitted to a facility for an eating disorder.⁹ Other studies have found that over 50 percent of substance abusers also fulfill criteria for BPD.

Self-destructive tendencies or suicidal gestures are very common among borderlines—indeed, they are one of the syndrome’s defining criteria. As many as 70 percent of BPD patients attempt suicide. The incidence of documented death by suicide is about 8 to 10 percent and even higher for borderline adolescents. A history of previous suicide attempts, a chaotic family life, and a lack of support systems increase the likelihood. The risk multiplies even more among borderline patients who also suffer from depressive or manic-depressive (bipolar) disorders, or from alcoholism or drug abuse.¹⁰^,¹¹

How Doctors Diagnose Psychiatric Disease

Before 1980, the previous two editions of the DSM described psychiatric illnesses in descriptive terms. However, DSM-III defined psychiatric disorders along structured, categorical paradigms; that is, several symptoms have been proposed to be suggestive of a particular diagnosis, and when a certain number of these criteria are met, the individual is considered to fulfill the categorical requirements for diagnosis. Interestingly, in the four revisions of DSM since 1980, only minor adjustments have been made to the definitional criteria for BPD. As we shall see shortly, nine criteria are associated with BPD, and an individual qualifies for the diagnosis if he exhibits five or more of the nine.

The categorical paradigm has stimulated controversy among psychiatrists, especially regarding the diagnosis of personality disorders. Unlike most other psychiatric illnesses, personality disorders are generally considered to develop in early adulthood and to persist for extended periods. These personality traits tend to be enduring and change only gradually over time. However, the categorical system of definitions may result in an unrealistically abrupt diagnostic change. In relation to BPD, a borderline patient who exhibits five symptoms of BPD theoretically ceases to be considered borderline if one symptom changes. Such a precipitous “cure” seems inconsistent with the concept of personality.

Some researchers have suggested adjusting the DSM to a dimensional approach to diagnosis. Such a model would attempt to determine what could be called “degrees of borderline,” since clearly some borderlines function at a higher level than others. These authors suggest that, rather than concluding that an individual is—or is not—borderline, the disorder should be recognized along a spectrum. This approach would put different weights on some of the defining criteria, depending upon which symptoms are shown by research to be more prevalent and enduring. Such a method could develop a representative, “pure” borderline prototype, which could standardize measures based on how closely a patient “matches” the description. A dimensional approach might be used to measure functional impairment. In this way, a higher or lower functioning borderline would be identified by her ability to manage her usual tasks of living. Another methodology would gauge particular traits, such as impulsivity, novelty-seeking, reward dependence, harm avoidance, neuroticism (capturing such characteristics as vulnerability to stress, poor impulse control, anxiety, mood lability, etc.) that have been associated with BPD.¹²^,¹³^,¹⁴ Such adaptations may more accurately measure changes and degrees of improvement, rather than merely determining the presence or absence of the disorder.

To understand the difference between these two definitional approaches, consider the way we perceive “gender.” The determination that one is male or female is a categorical definition, based on objective genetic and hormonal factors. Designations of masculinity or femininity, however, are dimensional concepts, influenced by personal, cultural, and other less objective criteria. It is likely that future iterations of the DSM will incorporate dimensional features of diagnosis.

Diagnosis of BPD

The most recent DSM-IV-TR lists nine categorical criteria for BPD, five of which must be present for diagnosis.¹⁵ At first glance, these criteria may seem unconnected or only peripherally related. When explored in depth, however, the nine symptoms are seen to be intricately connected, interacting with each other so that one symptom sparks the rise of another like the pistons of a combustion engine.

The nine criteria may be summarized as follows (each is described in depth in chapter 2):

1. Frantic efforts to avoid real or imagined abandonment.

2. Unstable and intense interpersonal relationships.

3. Lack of clear sense of identity.

4. Impulsiveness in potentially self-damaging behaviors, such as substance abuse, sex, shoplifting, reckless driving, binge eating.

5. Recurrent suicidal threats or gestures, or self-mutilating behaviors.

6. Severe mood shifts and extreme reactivity to situational stresses.

7. Chronic feelings of emptiness.

8. Frequent and inappropriate displays of anger.

9. Transient, stress-related feelings of unreality or paranoia.

This constellation of nine symptoms can be grouped into four primary areas toward which treatment is frequently directed:

1. Mood instability (criteria 1, 6, 7, and 8).

2. Impulsivity and dangerous uncontrolled behavior (criteria 4 and 5).

3. Interpersonal psychopathology (criteria 2 and 3).

4. Distortions of thought and perception (criterion 9).

Emotional Hemophilia

Beneath the clinical nomenclature lies the anguish experienced by borderlines and their families and friends. For the borderline, much of life is a relentless emotional roller coaster with no apparent destination. For those living with, loving, or treating the borderline, the trip can seem just as wild, hopeless, and frustrating.

Jennifer and millions of other borderlines are provoked to rage uncontrollably against the people they love most. They feel helpless and empty, with an identity splintered by severe emotional contradictions.

Mood changes come swiftly, explosively, carrying the borderline from the heights of joy to the depths of depression. Filled with anger one hour, calm the next, he often has little inkling about why he was driven to such wrath. Afterward, the inability to understand the origins of the episode brings on more self-hate and depression.

A borderline suffers a kind of “emotional hemophilia”; she lacks the clotting mechanism needed to moderate her spurts of feeling. Prick the delicate “skin” of a borderline and she will emotionally bleed to death. Sustained periods of contentment are foreign to the borderline. Chronic emptiness depletes him until he is forced to do anything to escape. In the grip of these lows, the borderline is prone to a myriad of impulsive, self-destructive acts—drug and alcohol binges, eating marathons, anorexic fasts, bulimic purges, gambling forays, shopping sprees, sexual promiscuity, and self-mutilation. He may attempt suicide, often not with the intent to die but to feel something, to confirm he is alive.

“I hate the way I feel,” confesses one borderline. “When I think about suicide, it seems so tempting, so inviting. Sometimes it’s the only thing I relate to. It is difficult not to want to hurt myself. It’s like, if I hurt myself, the fear and pain will go away.”

Central to the borderline syndrome is the lack of a core sense of identity. When describing themselves, borderlines typically paint a confused or contradictory self-portrait, in contrast to other patients who generally have a much clearer sense of who they are. To overcome their indistinct and mostly negative self-image, borderlines, like actors, are constantly searching for “good roles,” complete “characters” they can use to fill their identity void. So they often adapt like chameleons to the environment, situation, or companions of the moment, much like the title character in Woody Allen’s film Zelig, who literally assumes the personality, identity, and appearance of people around him.

The lure of ecstatic experiences, whether attained through sex, drugs, or other means, is sometimes overwhelming for the borderline. In ecstasy, he can return to a primal world where the self and the external world merge—a form of second infancy. During periods of intense loneliness and emptiness, the borderline will go on drug binges, bouts with alcohol, or sexual escapades (with one or several partners), sometimes lasting days at a time. It is as if when the struggle to find identity becomes intolerable, the solution is either to lose identity altogether or to achieve a semblance of self through pain or numbness.

The family background of a borderline is often marked by alcoholism, depression, and emotional disturbances. A borderline childhood is frequently a desolate battlefield, scarred with the debris of indifferent, rejecting, or absent parents, emotional deprivation, and chronic abuse. Most studies have found a history of severe psychological, physical, or sexual abuse in many borderline patients. Indeed, a history of mistreatment, witness to violence, or invalidation of experience by parents or primary caregivers distinguishes borderline patients from other psychiatric patients.¹⁶^,¹⁷

These unstable relationships carry over into adolescence and adulthood, where romantic attachments are highly charged and usually short-lived. The borderline will frantically pursue a man (or woman) one day and send him packing the next. Longer romances—usually measured in weeks or months rather than years—are usually filled with turbulence and rage, wonder, and excitement.

Splitting: The Black-and-White World of the Borderline

The world of a borderline, like that of a child, is split into heroes and villains. A child emotionally, the borderline cannot tolerate human inconsistencies and ambiguities; he cannot reconcile another’s good and bad qualities into a constant, coherent understanding of that person. At any particular moment, one is either “good” or “evil”; there is no in-between, no gray area. Nuances and shadings are grasped with great difficulty, if at all. Lovers and mates, mothers and fathers, siblings, friends, and psychotherapists may be idolized one day, totally devalued and dismissed the next.

When the idealized person finally disappoints (as we all do, sooner or later), the borderline must drastically restructure his strict, inflexible conceptualization. Either the idol is banished to the dungeon or the borderline banishes himself in order to preserve the “all-good” image of the other person.

This type of behavior, called “splitting,” is the primary defense mechanism employed by the borderline. Technically defined, splitting is the rigid separation of positive and negative thoughts and feelings about oneself and others; that is, the inability to synthesize these feelings. Most individuals can experience ambivalence and perceive two contradictory feeling states at one time; borderlines characteristically shift back and forth, entirely unaware of one emotional state while immersed in another.

Splitting creates an escape hatch from anxiety: the borderline typically experiences a close friend or relation (call him “Joe”) as two separate people at different times. One day, she can admire “Good Joe” without reservation, perceiving him as completely good; his negative qualities do not exist; they have been purged and attributed to “Bad Joe.” Other days, she can guiltlessly and totally despise “Bad Joe” and rage at his evil without self-reproach—for now his positive traits do not exist; he fully deserves the rage.

Intended to shield the borderline from a barrage of contradictory feelings and images—and from the anxiety of trying to reconcile those images—the splitting mechanism often and ironically achieves the opposite effect: the frays in the personality fabric become full-fledged rips; the sense of her own identity and the identities of others shift even more dramatically and frequently.

Stormy Relationships

Despite feeling continually victimized by others, a borderline desperately seeks out new relationships; for solitude, even temporary aloneness, is more intolerable than mistreatment. To escape the loneliness, the borderline will flee to singles bars, the arms of recent pickups, somewhere—anywhere—to meet someone who might save her from the torment of her own thoughts. The borderline is constantly searching for Mr. Goodbar.

In the relentless search for a structured role in life, the borderline is typically attracted to—and attracts to her—others with complementary personality traits. The domineering, narcissistic personality of Jennifer’s husband, for example, cast her in a well-defined role with little effort. He was able to give her an identity even if the identity involved submissiveness and mistreatment.

Yet, for a borderline, relationships often disintegrate quickly. Maintaining closeness with a borderline requires an understanding of the syndrome and a willingness to walk a long, perilous tight-rope. Too much closeness threatens the borderline with suffocation. Keeping one’s distance or leaving a borderline alone—even for brief periods—recalls the sense of abandonment he felt as a child. In either case, the borderline reacts intensely.

In a sense, the borderline is like an emotional explorer who carries only a sketchy map of interpersonal relations; he finds it extremely difficult to gauge the optimal psychic distance from others, particularly significant others. To compensate, he caroms back and forth from clinging dependency to angry manipulation, from gushes of gratitude to fits of irrational anger. He fears abandonment, so he clings; he fears engulfment, so he pushes away. He craves intimacy and is terrified of it at the same time. He winds up repelling those with whom he most wants to connect.

Job and Workplace Problems

Though borderlines have extreme difficulties managing their personal lives, many are able to function productively in a work situation—particularly if the job is well structured, clearly defined, and supportive. Some perform well for long periods, but then suddenly—because of a change in the job structure, or a drastic shift in personal life, or just plain boredom and a craving for change—they abruptly leave or sabotage their position and go on to the next opportunity. Many borderlines complain of frequent or chronic minor medical illnesses, leading to recurrent doctor visits and sick days.¹⁸

The work world can provide sanctuary from the anarchy of their social relationships. For this reason, borderlines frequently function best in highly structured work environments. The helping professions—medicine, nursing, clergy, counseling—also attract many borderlines who strive to achieve the power or control that elude them in social relationships. Perhaps more important, in these roles borderlines can provide the care for others—and receive the recognition from others—that they yearn for in their own lives. Borderlines are often very intelligent and display striking artistic abilities; fueled by easy access to powerful emotions, they can be creative and successful professionally.

But a highly competitive or unstructured job, or a highly critical supervisor, can trigger the intense, uncontrolled anger and the hypersensitivity to rejection to which the borderline is susceptible. The rage can permeate the workplace and literally destroy a career.

A “Woman’s Illness”?

Until recently, studies suggested that women borderlines outnumbered men by as much as three or four to one. However, more recent epidemiological research confirms that prevalence is similar in both genders, although women enter treatment more frequently. Moreover, severity of symptoms and disability are greater among women. These factors may help explain why females have been overrepresented in clinical trials. But there may be other factors that contribute to the impression that BPD is a “woman’s disease.”

Some critics feel that a kind of clinician bias operates with borderline diagnoses: Psychotherapists may perceive problems with identity and impulsivity as more “normal” in men; as a result, they may underdiagnose BPD among males. Where destructive behavior in women may be seen as a result of mood dysfunction, similar behavior in men may be perceived as antisocial. Where women in such predicaments may be directed toward treatment, men may instead be channeled through the criminal justice system where they may elude correct diagnosis forever.

BPD in Different Age Groups

Many of the features of the borderline syndrome—impulsivity, tumultuous relationships, identity confusion, mood instability—are major developmental hurdles for any adolescent. Indeed, establishing a core identity is the primary quest for both the teenager and the borderline. It follows, then, that BPD is diagnosed more commonly among adolescents and young adults than other age groups.¹⁹

BPD appears to be rare in the elderly. Recent studies demonstrate that the greatest decline in diagnosis of BPD occurs after the mid-forties. From this data, some researchers hypothesize that many older borderline adults “mature out” and are able to achieve stabilization over time. However, elderly adults must contend with a progressive decline in physical and mental functioning, which can be a perilous adaptive process for some aging borderlines. For a fragile identity, the task of altering expectations and adjusting self-image can exacerbate symptoms. The aging borderline with persistent psychopathology may deny deteriorating functions, project the blame for deficiencies onto others, and become increasingly paranoid; at other times, he may exaggerate handicaps and become more dependent.

Socioeconomic Factors

Borderline pathology has been identified in all cultures and economic classes in the United States. However, rates of BPD were significantly higher among those separated, divorced, widowed, or living alone, and among those with lower income and education. The consequences of poverty on infants and children—higher stress levels, less education, and lack of good child care, psychiatric care, and pregnancy care (perhaps resulting in brain insults or malnutrition)—might lead to higher incidence of BPD among the poor.

Geographic Borders

Although most of the theoretical formulations and empirical studies of the borderline syndrome have been conducted in the United States, other countries—Canada, Mexico, Israel, Sweden, Denmark, other Western European nations, and the former USSR—have recognized borderline pathologies within their populations.

Comparative studies are scant and contradictory at this point. For example, some studies indicate higher rates of BPD among Hispanics, while others do not confirm this finding. Some studies have found greater rates of BPD among Native American men. Consistent studies are meager but could provide great insight into the child-rearing, cultural, and social threads that compose the causal fabric of the syndrome.

Borderline Behavior in Celebrities and Fictional Characters

Whether the borderline personality is a new phenomenon or simply a new label for a long-standing, interrelated cluster of internal feelings and external behaviors is a topic of some interest in the mental health community. Most psychiatrists believe that the borderline syndrome has been around for quite some time; that its increasing prominence results not so much from its spreading (like an infectious disease or a chronic debilitating condition) in the minds of patients but from the awareness of clinicians. Indeed, many psychiatrists believe that some of Sigmund Freud’s most interesting cases of “neurosis” at the turn of the century would today be clearly diagnosed as borderline.²⁰

Perceived in this way, the borderline syndrome becomes an interesting new perspective from which to understand some of our most complex personalities—both past and present, real and fictional. Conversely, well-known figures and characters can be understood to illustrate different aspects of the syndrome. Along these lines, biographers and others have speculated that the term might apply to such wide-ranging figures as Princess Diana, Marilyn Monroe, Zelda Fitzgerald, Thomas Wolfe, T. E. Lawrence, Adolf Hitler, and Muammar al-Gadhafi. Cultural critics can observe borderline features in Blanche Dubois in A Streetcar Named Desire, Martha in Who’s Afraid of Virginia Woolf?, Sally Bowles in Cabaret, Travis Bickle in Taxi Driver, Howard Beale in Network, and Carmen in Bizet’s opera. Although borderline symptoms or behaviors may be spotted in these characters, BPD should not be assumed to necessarily cause or propel the radical actions or destinies of these real people or the fictional characters or the works in which they appear. Hitler, for example, was probably driven by mental malfunctions and societal forces much more prominent in his psyche than BPD; the root causes of Marilyn Monroe’s (alleged) suicide were probably more complex than to say simply it was caused by BPD. There is little evidence that the authors of Taxi Driver or Network were consciously trying to create a borderline protagonist. What the borderline syndrome does furnish is another perspective from which to interpret and analyze these fascinating personalities.

Advances in Research and Treatment

Since publication of the first edition of this book, significant strides have been made in research into the root causes of BPD and its treatment. Advances in our understanding of the biological, physiological, and genetic underpinnings of psychiatric diseases are exploding. Interactions between different parts of the brain and how emotions and executive reasoning intersect are being illuminated. The roles of neurotransmitters, hormones, and chemical reactions in the brain are better understood. Genetic vulnerability, how genes can be switched on and off, and the collision with life events to determine personality functioning are being studied. New psychotherapeutic techniques have evolved.

Long-term studies confirm that many patients recover over time and even more improve significantly. Over a decade 86 percent of borderline patients achieve sustained relief of symptoms, almost half of those within the first two years. However, despite diminution of defining symptoms, many of these patients continue to struggle in social and work or school environments. Although recurrence rates are as high as 34 percent, after ten years, full and complete recovery with good social and vocational functioning is achieved in 50 percent of patients.²¹^,²² Many borderline patients improve without consistent treatment, although continued therapy hastens improvement.²³

The Question of Borderline “Pathology”

To one degree or another, we all struggle with the same issues as the borderline—the threat of separation, fear of rejection, confusion about identity, feelings of emptiness and boredom. How many of us have not had a few intense, unstable relationships? Or flew into a rage now and then? Or felt the allure of ecstatic states? Or dreaded being alone, or gone through mood swings, or acted in a self-destructive manner in some way?

If nothing else, BPD serves to remind us that the line between “normal” and “pathological” may sometimes be a very thin one. Do we all display, to one degree or another, some symptoms of borderline personality? The answer is probably yes. Indeed, many of you reading this first chapter might be thinking that this sounds like you or someone you know. The discriminating factor, however, is that not all of us are controlled by the syndrome to the degree that it disrupts—or rules—our lives. With its extremes of emotion, thought, and behavior, BPD represents some of the best and worst of human character—and of our society in the nascent years of the twenty-first century. By exploring its depths and boundaries, we may be facing up to our ugliest instincts and our highest potentials—and the hard road we must travel to get from one point to the other.