BPD is one of ten personality disorders noted in DSM-IV-TR: in DSM terminology personality disorders are categorized on Axis II. (See Appendix A for a more detailed discussion of categorization in DSM-IV-TR.) These disorders are distinguished by a cluster of developing traits that become prominent in an individual’s behavior. These traits are relatively inflexible and result in maladaptive patterns of perceiving, behaving, and relating to others.

In contrast, state disorders (Axis I in DSM-IV-TR) are usually not as enduring as trait disorders. State disorders, such as depression, schizophrenia, anorexia nervosa, chemical dependency, are more often time- or episode-limited. Symptoms may emerge suddenly and then be resolved, as the patient returns to “normal.” Many times these illnesses are directly correlated with imbalances in the body’s biochemistry and can often be treated with medications, which virtually eliminate the symptoms.

Symptoms of a personality disorder, on the other hand, tend to be more durable traits and change only gradually; medications are, in general, less effective. Psychotherapy is primarily indicated, though other treatments, including medication, may alleviate many symptoms, especially severe agitation or depression (see chapter 9). In most cases, borderline and other personality disorders are a secondary diagnosis, describing the underlying characterological functioning of a patient who exhibits more acute and prominent symptoms of a state disorder.

Comparisons to Other Disorders

Because the borderline syndrome often masquerades as a different illness and is often associated with other illnesses, clinicians often fail to recognize that BPD may be an important component in evaluating a patient. As a result, the borderline often becomes, like Carrie, a well-traveled patient, evaluated by multiple hospitals and doctors and accompanied throughout life by an assortment of diagnostic labels.

BPD can interact with other disorders in several ways (see Figure 2-1). First, BPD can coexist with state (Axis I) disorders in such a way that borderline pathology is camouflaged. For example, BPD may be submerged in the wake of a more prominent and severe depression. After resolution of the depression with antidepressant medications, borderline characteristics may surface and only then be recognized as the underlying character structure requiring further treatment.

Second, BPD may be closely linked and perhaps even contribute to the development of another disorder. For example, the impulsivity, self-destructiveness, interpersonal difficulties, deflated self-image, and moodiness often exhibited by patients with substance abuse or eating disorders may be more reflective of BPD than the primary Axis I disorder. Although it could be argued that chronic abuse of alcohol could eventually alter personality characteristics in such a way that a borderline pattern could evolve secondarily, it seems more likely that underlying character pathology would develop first and lead to alcoholism.

FIGURE 2-1. Schematic of position of BPD in relation to other mental disorders.

The question of which is the chicken and which is the egg may be difficult to resolve, but the development of illnesses associated with BPD may represent a kind of psychological vulnerability to stress. Just as certain individuals have genetic and biological dispositions to physical diseases—heart attacks, cancers, gastrointestinal disorders, etc.—many also have biologically determined propensities to psychiatric illnesses, particularly when stress is added to an underlying vulnerability to BPD. Thus, under stress, one borderline turns to drugs, another develops an eating disorder, still another becomes severely depressed.

Third, BPD may so completely mimic another disorder that the patient may be erroneously diagnosed with schizophrenia, anxiety, bipolar disease, attention deficit/hyperactivity disorder (ADHD), or other illnesses.

Comparison to Schizophrenia

Schizophrenic patients are usually much more severely impaired than borderlines and less capable of manipulating and relating to others. Both kinds of patients may experience agitated, psychotic episodes, but these are usually less consistent and less pervasive over time for borderlines. Schizophrenics are much more likely to grow accustomed to their hallucinations and delusions and are often less disturbed by them. Additionally, both may be destructive and self-mutilating, but whereas the borderline usually can function appropriately, the schizophrenic is much more severely impaired socially.

Comparison to Affective Disorders (Bipolar and Depressive Disorders)

“Mood swings” and “racing thoughts” are common patient complaints, to which the knee-jerk diagnostic response from the clinician is to diagnose depression or bipolar disorder (manic depression). However, such symptoms are consistent with BPD, and even ADHD, both of which are significantly more prevalent than bipolar disorder. The differences between these syndromes are dramatic. For those afflicted with bipolar disorder or depression, episodes of depression or mania represent radical departures in functioning. Mood changes last from days to weeks. Between mood swings, these individuals maintain relatively normal lives and can usually be treated effectively with medications. Borderlines, in contrast, typically have difficulties in functioning (at least internally) even when not displaying prominent mood swings. When self-destructive, threatening suicide, hyperactive, or experiencing wide and rapid mood swings, the borderline may appear bipolar, but the borderline’s mood variations are more transient (lasting hours, rather than days or weeks), and more often reactive to environmental stimuli.³

BPD and ADHD

Individuals with ADHD are subjected to a constant scramble of flashing cognitions. Like borderlines, they often experience wild mood changes, racing thoughts, impulsivity, anger outbursts, impatience, and low frustration tolerance; have a history of drug or alcohol abuse (self-medicating) and torturous relationships; and are bored easily. Indeed, many borderline personality characteristics correspond to the “typical ADHD temperament,” such as frequent novelty-seeking (searching for excitement) coupled with low reward dependence (lack of concern for immediate consequences).⁴ Not surprisingly, several studies have noted correlations between these diagnoses. Some prospective studies have noted that children diagnosed with ADHD frequently develop a personality disorder, especially BPD, as they get older. Retrospective researchers have determined that adults with the diagnosis of BPD often fit a childhood diagnosis of ADHD.⁵^,⁶^,⁷ Whether one illness causes the other, whether they frequently travel together, or, possibly, if they are merely related manifestations of the same disorder remains for intriguing further investigation. Interestingly, one study demonstrated that treatment of ADHD symptoms also ameliorated BPD symptoms in patients diagnosed with both disorders.⁸

BPD and Pain

Borderlines have been demonstrated to reflect paradoxical reactions to pain. Many studies have shown a significantly decreased sensitivity to acute pain, particularly when self-inflicted (see “Self-Destruction” on page 45). However, borderlines exhibit greater sensitivity to chronic pain. This “pain paradox” appears unique to borderlines and has not been satisfactorily explained. Some posit that acute pain, especially when self-inflicted, satisfies certain psychological needs for the patient and is associated with changes in electrical brain activity and perhaps quick release of endogenous opioids, the body’s own narcotics. However, ongoing pain, experienced outside the borderline’s control, may result in less internal analgesic protection and cause more anxiety.⁹^,¹⁰

BPD and Somatization Disorder

The borderline may focus on his physical ills, complaining loudly and dramatically to medical personnel and acquaintances, in order to maintain dependency relationships with them. He may be considered merely a hypochondriac, while the underlying understanding of his problems is completely ignored. Somatization disorder is a condition defined by the patient’s multiple physical complaints (including pain, gastric, neurological, and sexual symptoms), unexplained by any known medical condition. In hypochondriasis the patient is convinced he has a terrible disease despite a negative medical evaluation.

BPD and Dissociative Disorders

Dissociative disorders include such phenomena as amnesia, feelings of unreality about oneself (depersonalization) or about the environment (derealization). The most extreme form of dissociation is dissociative identity disorder (DID), previously referred to as “multiple personality.” Almost 75 percent of individuals with BPD experience some dissociative phenomena.¹¹ The prevalence of BPD in those suffering from the most severe form of dissociation, DID, as a primary diagnosis is even greater.¹² Both disorders share common symptoms—impulsivity, anger outbursts, disturbed relationships, severe mood changes, and a propensity for self-mutilation. There is frequently a childhood history of mistreatment, abuse, or neglect.

BPD and Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a complex of symptoms that follows an extraordinarily severe traumatic event, such as a natural disaster or combat. It is characterized by intense fear, emotional re-experiencing of the event, nightmares, irritability, exaggerated startle response, avoidance of associated places or activities, and a sense of helplessness. Since both BPD and PTSD have frequently been associated with a history of extreme abuse in childhood and reflect similar symptoms—such as extreme emotional reactions and impulsivity—some have posited that they are the same illness. Although some studies indicate that they may occur together as much as 50 percent or more of the time, they are distinctly different disorders with different defining criteria.¹³

BPD and Associated Personality Disorders

Many characteristics of BPD overlap with those of other personality disorders. For example, the dependent personality shares with the borderline the features of dependency, avoidance of being alone, and strained relationships. But the dependent personality lacks the self-destructiveness, anger, and mood swings of a borderline. Similarly, the schizotypal personality exhibits poor relations with others and difficulty in trusting, but is more eccentric and less self-destructive. Often a patient exhibits enough characteristics of two or more personality disorders to warrant diagnoses for each. For example, a patient may demonstrate characteristics that lead to diagnoses of both borderline personality disorder and obsessive-compulsive personality disorder.

In DSM-IV-TR, BPD is grouped in a cluster of personality disorders that generally reflect dramatic, emotional, or erratic features (see Appendix A). The others in this group are narcissistic, antisocial, and histrionic personality disorders, to which BPD is often compared.

Both borderlines and narcissists display hypersensitivity to criticism; failures or rejections can precipitate severe depression. Both exploit others; both demand almost constant attention. The narcissistic personality, however, usually functions at a higher level. He exhibits an inflated sense of self-importance (sometimes camouflaging desperate insecurity), displays disdain for others, and lacks even a semblance of empathy. In contrast, the borderline has a lower self-esteem and is highly dependent on others’ reassurance. The borderline desperately clings to others and is usually more sensitive to their reaction.

Like the borderline, the antisocial personality exhibits impulsivity, poor tolerance of frustration, and manipulative relationships. The antisocial personality, however, lacks a sense of guilt or conscience; he is more detached and is not purposefully self-destructive.

The histrionic personality shares with the borderline tendencies of attention-seeking, manipulativeness, and shifting emotions. The histrionic, however, usually develops more stable roles and relationships. He is usually more flamboyant in speech and manner, and emotional reactions are exaggerated. Physical attractiveness is the histrionic’s primary concern. One study compared psychological and social functioning in patients with BPD, schizotypal, obsessive-compulsive, or avoidant personality disorders and patients with major depression. Patients with borderline and schizotypal personality disorders were significantly more functionally impaired than those with the other personality disorders and those with major depression.¹⁴

BPD and Substance Abuse

BPD and chemical abuse are frequently associated. Nearly one-third of those with a lifetime diagnosis of substance abuse also fulfill criteria for BPD. And over 50 percent of BPD inpatients also abuse drugs or alcohol.¹⁵^,¹⁶ Alcohol or drugs might reflect self-punishing, angry, or impulsive behaviors, a craving for excitement, or a mechanism of coping with loneliness. Drug dependency may be a substitute for nurturing social relationships, a familiar, comforting way to stabilize or self-medicate fluctuating moods, or a way to establish some sense of belonging or self-identification. These possible explanations for the appeal of chemical abuse are also some of the defining criteria for BPD.

The Anorexic/Bulimic Borderline or the Borderline Anorexic/Bulimic?

Anorexia nervosa and bulimia have become major health problems in this country, especially among young women. Eating disorders are fueled by a fundamental distaste for one’s own body and a general disapproval of one’s identity. The anorexic sees herself in absolute black or white extremes—as either obese (which she always feels) or thin (which she feels she never completely achieves). Since she constantly feels out of control, she impulsively utilizes starvation or binging and purging to maintain an illusion of self-control. The similarity of this pattern to the borderline pattern has led many mental health professionals to infer a strong connection between the two. Indeed, many studies confirm the high prevalence of personality disorders in those with eating disorders and, conversely, the frequent co-occurrence of personality disorders in those with any eating disorder. ¹⁷

BPD and Compulsive Behaviors

Certain compulsive or destructive behaviors may reflect borderline patterns. For example, a compulsive gambler will continue to gamble despite a shortage of funds. He may be seeking a thrill from a world that habitually leaves him bored, restless, and numb. Or the gambling may be an expression of impulsive self-punishment. Shoplifters often steal items they do not need. Fifty percent of bulimics exhibit kleptomania, drug use, or promiscuity.¹⁸ When these behaviors are governed by compulsion, they may represent a need to feel or a need to self-inflict pain.

Promiscuity often reflects a need for constant love and attention from others, in order to hold on to positive feelings about oneself. The borderline typically lacks consistent, positive self-regard and requires continuous reassurance. A borderline woman, lacking in self-esteem, may perceive her physical attractiveness as her only asset and may require confirmation of her worth by engaging in frequent sexual encounters. Such involvements avoid the pain of being alone and create artificial relationships she can totally control. Feeling desired can instill a sense of identity. When self-punishment becomes a prominent part of the psychodynamics, humiliation and masochistic perversions may enter the relationships. From this perspective, it is logical to speculate that many prostitutes and pornographic actors and models may be borderline.

Difficulties with relationships may result in private, ritualistic thinking and behaviors, often expressed as obsessions or compulsion. A borderline may develop specific phobias as he employs magical thinking to deal with fears; sexual perversions may evolve as a mechanism to approach intimacy.

Appeal of Cults

Because borderlines yearn for direction and acceptance, they may be attracted to strong leaders of disciplined groups. The cult can be very enticing since it provides instant and unconditional acceptance, automatic intimacy, and a paternalistic leader who will be readily idealized. The borderline can be very vulnerable to such a black-and-white worldview in which “evil” is personified by the outside world and “good” is encompassed within the cult group.

BPD and Suicide

As many as 70 percent of BPD patients attempt suicide, and the rate of completed suicide approaches 10 percent, almost a thousand times the rate seen in the general population. In the high-risk group of adolescents and young adults (ages fifteen to twenty-nine), BPD was diagnosed in a third of suicide cases. Hopelessness, impulsive aggressiveness, major depression, concurrent drug use, and a history of childhood abuse increase the risk. Although anxiety symptoms are often associated with suicide in other illnesses, borderlines who exhibit significant anxiousness are actually less likely to commit suicide.¹⁹^, ²⁰^, ²¹

Clinical Definition of Borderline Personality Disorder

The current official definition of borderline pathology is contained in the DSM-IV-TR diagnostic criteria of Borderline Personality Disorder.²² This designation emphasizes descriptive, observable behavior.

The diagnosis of BPD is confirmed when at least five of the following nine criteria are present.

“Others Act Upon Me, Therefore I Am”

Criterion 1. Frantic efforts to avoid real or imagined abandonment.

Just as an infant cannot distinguish between the temporary absence of her mother and her “extinction,” the borderline often experiences temporary aloneness as perpetual isolation. As a result, the borderline becomes severely depressed over the real or perceived abandonment by significant others and then enraged at the world (or whoever is handy) for depriving her of this basic fulfillment.

Fears of abandonment in the borderline can even be measured in the brain. One study utilized PET scanning to demonstrate that women with BPD experienced alterations of blood flow in certain areas of the brain when exposed to memories of abandonment.²³ Particularly when they are alone, borderlines may lose the sensation of existing, of feeling real. Rather than embracing Descartes’ “I think, therefore I am” principle of existence, they live by a philosophy closer to “Others act upon me, therefore I am.”

The theologian Paul Tillich wrote that “loneliness can be conquered only by those who can bear solitude.” Because the borderline finds solitude so difficult to tolerate, she is trapped in a relentless metaphysical loneliness from which the only relief comes in the form of the physical presence of others. So she will often rush to singles bars or other crowded haunts, often with disappointing—or even violent—results.

In Marilyn: An Untold Story, Norman Rosten recalled Marilyn Monroe’s hatred of being alone. Without people constantly around her, she would fall into a void, “endless and terrifying.”²⁴

For most of us, solitude is longed for, cherished, a rare opportunity to reflect on memories and matters important to our well-being—a chance to get back in touch with ourselves, to rediscover who we are: “The walls of an empty room are mirrors that double and redouble our sense of ourselves,” the late John Updike wrote in The Centaur.

But the borderline, with only the weakest sense of self, looks back at only vacant reflections. Solitude recapitulates the panic that the borderline experienced as a child when faced with the prospect of abandonment by parents: Who will take care of me? The pain of loneliness can only be relieved by the rescue of a fantasized lover, as expressed in the lyrics of countless love songs.

The Relentless Search for Mr./Ms. Right

Criterion 2. Unstable and intense interpersonal relationships, with marked shifts in attitudes toward others (from idealization to devaluation or from clinging dependency to isolation and avoidance), and prominent patterns of manipulation of others.

The borderline’s unstable relationships are directly related to his intolerance of separation and fear of intimacy. The borderline is typically dependent, clinging, and idealizing until the lover, spouse, or friend repels or frustrates these needs with some sort of rejection or indifference, then the borderline caroms to the other extreme—devaluation, resistance to intimacy, and outright avoidance. A continual tug-of-war develops between the wish to merge and be taken care of, on the one hand, and the fear of engulfment, on the other. For the borderline, engulfment means the obliteration of separate identity, the loss of autonomy, and a feeling of nonexistence. The borderline vacillates between a desire for closeness to relieve the emptiness and boredom, and fear of intimacy, which is perceived as the thief of self-confidence and independence.

In relationships, these internal feelings are dramatically translated into intense, shifting, manipulative couplings. The borderline often makes unrealistic demands of others, appearing to observers as spoiled. Manipulativeness is manifested through physical complaints and hypochondriasis, expressions of weakness and helplessness, provocative actions, and masochistic behaviors. Suicidal threats or gestures are often used to obtain attention and rescue. The borderline may use seduction as a manipulative strategy, even with someone known to be inappropriate and inaccessible, such as a therapist or minister.

Though very sensitive to others, the borderline lacks true empathy. He may be dismayed to encounter an acquaintance, such as teacher, coworker, or therapist, outside of his usual place of business because it is difficult to conceive of that person as having a separate life. Furthermore, he may not understand or be extremely jealous of his therapist’s separate life, or even of other patients he may encounter.

The borderline lacks “object constancy,” the ability to understand others as complex human beings who nonetheless can relate in consistent ways. The borderline experiences another on the basis of his most recent encounter, rather than on a broader-based, consistent series of interactions. Therefore, a constant, predictable perception of another person never emerges—the borderline, as if afflicted with a kind of targeted amnesia, continues to respond to that person as someone new on each occasion.

Because of the borderline’s inability to see the big picture, to learn from previous mistakes, and to observe patterns in his own behavior, he often repeats destructive relationships. A female borderline, for example, will typically return to her abusive ex-husband, who proceeds to abuse her again; a male borderline frequently couples with similar, inappropriate women with whom he repeats sadomasochistic affiliations. Since the borderline’s dependency is often disguised as passion, the spouse persists in the destructive relationship “because I love him.” Later, when the relationship disintegrates, one partner can blame the other’s pathology. Thus, as is often heard in the therapist’s office, “My first wife was a borderline!”

The borderline’s endless quest is to find a perfect caregiver who will be all-giving and omnipresent. The search often leads to partners with complementary pathology: both lack insight into their mutual destructiveness. For example, Michelle desperately craves protection and comfort from a man. Mark displays bravura self-assurance; even though the self-assurance covers his deep insecurity, it fits the bill for Michelle. Just as Michelle needs Mark to be her protective white knight, so Mark needs Michelle to remain helpless and dependent on his beneficence. After a while, both fail to live up to their assigned stereotypes. Mark cannot bear the narcissistic wounds of challenge or failure and begins to cover his frustrations with alcohol and by physically abusing Michelle. Michelle bristles under his controlling yoke, yet becomes frightened when she sees his weaknesses. The dissatisfactions lead to more provocation and more conflict.

Afflicted with self-loathing, the borderline distrusts others’ expressions of caring. Like Groucho Marx, he would never belong to a club that would have him as a member. Sam, for example, was a twenty-one-year-old college student whose chief complaint in therapy was “I need a date.” An attractive man with serious interpersonal problems, Sam characteristically approached women he deemed inaccessible. However, whenever his overtures were accepted, he immediately devalued the woman as no longer desirable.

All of these characteristics make it difficult for borderlines to achieve real intimacy. As Carrie relates, “A few men have wanted to marry me, but I have a big problem with getting close or being touched. I can’t tolerate it.” The borderline cannot seem to gain enough independence to be dependent in healthy, rather than desperate, ways. True sharing is sacrificed to a demanding dependency and a desperate need to join with another person in order to complete one’s own identity, as kind of Siamese twins of the soul. “You complete me,” the famous line from the film Jerry Maguire, turns into an elusive goal that is always just out of reach.

Who Am I?

Criterion 3. Marked and persistent identity disturbance manifested by an unstable self-image or sense of self.

Borderlines lack a constant, core sense of identity, just as they lack a constant, core conceptualization of others. The borderline does not accept her own intelligence, attractiveness, or sensitivity as constant traits, but rather as comparative qualities to be continually re-earned and judged against others’. The borderline may view herself as intelligent, for example, based solely on the results of a just-administered IQ test. Later that day when she makes a “dumb mistake” she will revert to seeing herself as “stupid.” The borderline considers herself attractive until she spies a woman whom she feels is prettier, then she feels ugly. Surely, the borderline envies the self-acceptance of Popeye—“I yam what I yam.” As in her close relationships, the borderline becomes mired in a kind of amnesia—about herself. The past becomes obfuscated; she is much like the demanding boss who continually asks herself and others, “Yeah, so? What have you done for me lately?”

For the borderline, identity is graded on a curve. Who she is (and what she does) today determines her worth, with little regard to what has come before. The borderline allows herself no laurels on which to rest. Like Sisyphus, she is doomed to roll the boulder repeatedly up the hill, needing to prove herself over and over again. Self-esteem is only attained through impressing others, so pleasing others becomes critical to loving herself.

In his book Marilyn, Norman Mailer describes how Marilyn Monroe’s search for identity became Marilyn’s driving force, absorbing all aspects of her life:

What an obsession is identity! We search for it, because the private sensation when we are in our own identity is that we feel sincere as we speak, we feel real, and this little phenomenon of good feeling conceals an existential mystery as important to psychology as the cogito ergo sum—it is nothing less than that the emotional condition of feeling real is, for whatever reason, so far superior to the feeling of a void in oneself that it can become for protagonists like Marilyn a motivation more powerful than the instinct of sex, or the hunger for position or money. Some will give up love or security before they dare to lose the comfort of identity.²⁵

Later, Marilyn found sustenance in acting, particularly in “the Method”:

Actors in the Method will act out; their technique is designed like psychoanalysis itself, to release emotional lava, and thereby enable the actor to become acquainted with his depths, then possess them enough to become possessed by his role. A magical transaction. We can think of Marlon Brando in A Streetcar Named Desire. To be possessed by a role is satori (or intuitive illumination) for an actor because one’s identity can feel whole so long as one is living in the role. ²⁶

The borderline’s struggle in establishing a consistent identity is related to a prevailing sense of inauthenticity—a constant sense of “faking it.” Most of us experience this sensation at various times in our lives. When one starts a new job, for example, one tries to exude an air of knowledge and confidence. After gaining experience, the confidence becomes increasingly genuine because one has learned the system and no longer needs to fake it. As Kurt Vonnegut wrote, “We are what we pretend to be.” Or, as some phrase it, “Fake it ’til you make it.”

The borderline never reaches that point of confidence. He continues to feel like he is faking it and is terrified that he will, sooner or later, be “found out.” This is particularly true when the borderline achieves some kind of success—it feels misplaced, undeserved.

This chronic sense of being a fake or sham probably originates in childhood. As explored in chapter 3, the pre-borderline often grows up feeling inauthentic due to various environmental circumstances—suffering physical or sexual abuse or being forced to adopt an adult’s role while still a child or to parent his own sick parent. At the other extreme, he may be discouraged from maturing and separating, and may be trapped in a dependent child’s role, well past an appropriate time for separation. In all of these situations, the borderline never develops a separate sense of self but continues to “fake” a role that is prescribed by someone else. (“He never chooses an opinion,” was how Leo Tolstoy described one of his characters, “he just wears whatever happens to be in style.”) If he fails in the role, he fears he will be punished; if he succeeds, he is sure he will soon be uncovered as a fraud and be humiliated.

Unrealistic attempts at achieving a state of perfection are often part of the borderline pattern. For example, a borderline anorexic might try to maintain a constant low weight and become horrified if it varies as little as one pound, unaware that this expectation is unrealistic. Perceiving themselves as static, rather than in a dynamic state of change, borderlines may view any variation from this inflexible self-image as shattering.

Conversely, the borderline may search for satisfaction in the opposite direction—by frequently changing jobs, careers, goals, friends, sometimes even gender. By altering external situations and making drastic changes in lifestyle, he hopes to achieve inner contentment. Some instances of so-called midlife crisis or male menopause represent an extreme attempt to ward off fears of mortality or deal with disappointments in life choices. An adolescent borderline may constantly change his clique of friends—from “jocks” to “burnouts” to “brains” to “geeks”—hoping to achieve a sense of belonging and acceptance. Even sexual identity can be a source of confusion for the borderline. Some writers have noted an increased incidence of homosexuality, bisexuality, and sexual perversions among borderline personalities.²⁷

Cult groups that promise unconditional acceptance, a structured social framework, and a circumscribed identity are powerful attractions for the borderline personality. When the individual’s identity and value system merge with the accepting group’s, the faction’s leader assumes extraordinary power—to the point where he can induce followers to emulate his actions, even if fatal, as witnessed by the Jonestown Massacre in 1978, the fatal conflict with Branch Davidians in 1993, and the mass suicides of the Heaven’s Gate cult in 1997.

Aaron, after dropping out of college, attempted to assuage his feelings of aimlessness by joining the “Moonies.” He left the cult after two years, only to return after two more years of directionless wandering among different cities and jobs. Ten months later he left the group again, but this time, lacking a stable set of goals or a comfortable sense of who he was or what he wanted, he attempted suicide.

The phenomenon of “cluster suicides,” especially among teenagers, may reflect weaknesses in identity formation. The national suicide rate dramatically leaps upward after the suicide of a famous person, such as Marilyn Monroe or Kurt Cobain. The same dynamics may operate among adolescents with fragile identity structures: they are susceptible to the suicidal tendencies of the peer group leader or of another suicidal teenage group in the same region.

The Impulsive Character

Criterion 4. Impulsiveness in at least two areas that are potentially self-destructive, e.g., substance abuse, sexual promiscuity, gambling, reckless driving, shoplifting, excessive spending, or overeating.

The borderline’s behaviors may be sudden and contradictory, since they result from strong, momentary feelings—perceptions that represent isolated, unconnected snapshots of experience. The immediacy of the present exists in isolation, without the benefit of the experience of the past, or the hopefulness of the future. Because historical patterns, consistency, and predictability are unavailable to the borderline, similar mistakes are repeated again and again. The 2001 film Memento presents metaphorically what the borderline faces on a regular basis. Afflicted with short-term memory loss, insurance investigator Leonard Selby must hang Polaroids and Post-it notes all over his room—and even tattoo messages on his own body—to remind himself what has happened only hours or minutes before. (In one car-chase scene, trying to avenge his wife’s murder, he cannot remember if he is chasing someone—or being chased!) The film dramatically illustrates the loneliness of a man who constantly feels “like I just woke up.” The borderline’s limited patience and need for immediate gratification may be connected to behaviors that define other BPD criteria: Impulsive conflict and rage may emerge from the frustrations of a stormy relationship (criterion 2); precipitous mood changes (criterion 6) may result in impulsive outbursts; inappropriate outbursts of anger (criterion 8) may develop from a failure to control impulses; self-destructive or self-mutilating behaviors (criterion 5) may result from the borderline’s frustrations. Often, impulsive actions such as drug and alcohol abuse serve as defenses against feelings of loneliness and abandonment.

Joyce was a thirty-one-year-old divorced woman who increasingly turned to alcohol after her divorce and her husband’s subsequent remarriage. Though attractive and talented, she let her work deteriorate and spent more time at bars. “I made a career out of avoiding,” she later said. When the pain of being alone and feeling abandoned became too great, she would use alcohol as anesthesia. She would sometimes pick up men and take them home with her. Characteristically, after such alcohol or sexual binges, she would berate herself with guilt and feel deserving of her husband’s abandonment. Then the cycle would start again, as she required more punishment for her worthlessness. Thus, self-destructiveness became both a means of avoiding pain and a mechanism for inflicting it as expiation for her sins.

Self-Destruction

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

Suicidal threats and gestures—reflecting both the borderline’s propensity for overwhelming depression and hopelessness and his knack for manipulating others—are prominent features of BPD.

As many as 75 percent of borderlines have a history of self-mutilation, and the vast majority of those have made at least one suicide attempt.²⁸ Often, the frequent threats or halfhearted suicide attempts are not a wish to die but rather a way to communicate pain and a plea for others to intervene. Unfortunately, when habitually repeated, these suicidal gestures often lead to just the opposite scenario—others get fed up and stop responding, which may result in progressively more serious attempts. Suicidal behavior is one of the most difficult BPD symptoms for family and therapists to cope with: addressing it can result in endless unproductive confrontations; ignoring it can result in death (see chapters 6-8). Although many of the defining criteria for BPD diminish over time, the risk of suicide persists throughout the life cycle.²⁹ Borderlines with a childhood history of sexual abuse are ten times more likely to attempt suicide.³⁰

Self-mutilation—except when clearly associated with psychosis—is the hallmark of BPD. This behavior, more closely connected to BPD than any other psychiatric malady, may take the form of self-inflicted wounds to the genitals, limbs, or torso. For these borderlines, the body becomes a road map highlighted with a lifetime tour of self-inflicted scars. Razors, scissors, fingernails, and lit cigarettes are some of the more common instruments used; excessive use of drugs, alcohol, or food can also inflict the damage.

Often, self-mutilation begins as an impulsive, self-punishing action, but over time it may become a studied, ritualistic procedure. In such instances the borderline may carefully scar body areas that are covered by clothing—which illustrates the borderline’s intense ambivalence: he feels compelled to flamboyantly self-punish, yet he carefully conceals the evidence of his tribulation. Though many people get tattoos for decorative reasons, on a societal level the increasing fascination with tattoos and piercings over the past two decades may be less a fashion trend than a reflection of borderline tendencies in society (see chapter 4).

Jennifer (see chapter 1) would fulfill her need to self-inflict pain by scratching her wrists, abdomen, and waist, leaving deep fingernail marks that could easily be covered.

Sometimes the self-punishment is more indirect. The borderline may often be the victim of recurrent “quasi accidents.” He may provoke frequent fights. In these incidents, the borderline feels less directly responsible; circumstances or others provide the violence for him.

When Harry, for example, broke up with his girlfriend, he blamed his parents. They had not been supportive enough or friendly enough, he thought, and when she ended the affair after six years, he was forlorn. At twenty-eight he continued to live in an apartment paid for by his parents and worked sporadically in his father’s office. Earlier in his life he had attempted suicide but decided he wouldn’t give his parents “the satisfaction” of killing himself. Instead, he engaged in increasingly dangerous behaviors. He had numerous automobile accidents, some while intoxicated, and continued to drive despite the revocation of his driver’s license. He frequented bars where he sometimes picked fights with much bigger men. Harry recognized the destructiveness of his behavior and sometimes wished that “one of these times I would just die.”

These dramatic self-destructive behaviors and threats may be explained in several ways. The self-inflicted pain may reflect the borderline’s need to feel, to escape an encapsulating numbness. Borderlines form a kind of insulating bubble that not only protects them from emotional hurt but also serves as a barrier from the sensations of reality. The experience of pain, then, becomes an important link to existence. Often, however, the inflicted pain is not strong enough to transcend this barrier (though the blood and scars may be fascinating for the borderline to observe), in which case the frustration may compel him to accelerate attempts to induce pain.

Self-induced pain can also function as a distraction from other forms of suffering. One patient, when feeling lonely or afraid, would cut different parts of her body as a way “to take my mind off” the loneliness. Another would bang her head in the throes of stress-related migraine headaches. Relief of inner tension may be the most common reason for self-harming.³¹

Self-damaging behavior can also serve as an expiation for sin. One man, guilt-ridden after the breakup of his marriage for which he totally blamed himself, would repeatedly drink gin—a taste he abhorred—until reaching the point of retching. Only after enduring this discomfort and humiliation would he feel redeemed and able to return to his usual routine.

Painful, self-destructive behavior may be employed in an attempt to constrict actions that are felt to be dangerously out of control. One adolescent boy cut his hands and penis to dissuade himself from masturbation, an act he considered loathsome. He hoped that the memory of the pain would prevent him from further indulging in this repugnant behavior.

Impulsive, self-destructive acts (or threats) may result from a wish to punish another person, often a close relation. One woman consistently described her promiscuous behavior (often involving masochistic, degrading rituals) to her boyfriend. These affairs invariably occurred when she was angry and wanted to punish him.

Finally, self-destructive behavior can evolve from a manipulative need for sympathy or rescue. One woman, after arguments with her boyfriend, repeatedly slashed her wrists in his presence, forcing him to secure medical assistance for her.

Many borderlines deny feeling pain during self-mutilation and even report a calm euphoria after it. Before hurting themselves, they may experience great tension, anger, or overwhelming sadness; afterward there is a sensation of release and relief from anxiety.

This relief may result from psychological or physiological factors, or a combination of both. Physicians have long recognized that following severe physical trauma, such as battle wounds, the patient may experience an unexpected calm and a kind of natural anesthesia despite the lack of medical attention. Some have hypothesized that during such times, the body releases biological substances, called endorphins, the body’s internal opiate drugs (like morphine or heroin), which serve as the organism’s self-treatment of pain.

Radical Mood Shifts

Criterion 6. Affective instability due to marked reactivity of mood with severe episodic shifts to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days.

The borderline undergoes abrupt mood shifts, lasting for short periods—usually hours. His base mood is not usually calm and controlled, but more often either hyperactive and irrepressible or pessimistic, cynical, and depressed.

Audrey was giddy with excitement as she flooded Owen with kisses after he surprised her with flowers he bought on the way home from work. As he washed up for dinner, Audrey took a call from her mother, who again berated her for not calling to ask about her constant body aches. By the time Owen returned from the bathroom, Audrey had mutated into a raging harridan, screaming at him for not helping with dinner. He could only sit there, stunned and perplexed at the transformation.

Always Half Empty

Criterion 7. Chronic feelings of emptiness.

Lacking a core sense of identity, borderlines commonly experience a painful loneliness that motivates them to search for ways to fill up the “holes.”

The painful, almost physical sensation is lamented by Shakespeare’s Hamlet: “I have of late—but wherefore I know not—lost all my mirth, forgone all custom of exercises; and indeed it goes so heavily with my disposition, that this goodly frame the earth seems to me a sterile promontory.”

Tolstoy defined boredom as “the desire for desires”; in this context it can be seen that the borderline’s search for a way to relieve the boredom often results in impulsive ventures into destructive acts and disappointing relationships. In many ways the borderline seeks out a new relationship or experience not for its positive aspects but to escape the feeling of emptiness, acting out the existential destinies of characters described by Sartre, Camus, and other philosophers.

The borderline frequently experiences a kind of existential angst, which can be a major obstacle in treatment for it saps the motivational energy to get well. From this feeling state radiate many of the other features of BPD. Suicide may appear to be the only rational response to a perpetual state of emptiness. The need to fill the void or relieve the boredom can lead to outbursts of anger and self-damaging impulsiveness—especially drug abuse. Abandonment may be more acutely felt. Relationships may be impaired. A stable sense of self cannot be established in an empty shell. And mood instability may result from the feelings of loneliness. Indeed, depression and feelings of emptiness often reinforce each other.

Raging Bull

Criterion 8. Inappropriate, intense anger, or lack of control of anger, e.g., frequent displays of temper, constant anger, recurrent physical fights.

Along with affective instability, anger is the most persistent symptom of BPD over time.³²

The borderline’s outbursts of rage are as unpredictable as they are frightening. Violent scenes are disproportionate to the frustrations that trigger them. Domestic fracases that may involve chases with butcher knives and thrown dishes are typical of borderline rage. The anger may be sparked by a particular (and often trivial) offense, but underneath the spark lies an arsenal of fear from the threat of disappointment and abandonment. After a disagreement over a trivial remark about their contrasting painting styles, Vincent van Gogh picked up a butcher knife and chased his good friend, Paul Gauguin, around his house and out the door. He then turned his rage on himself, using the same knife to slice off a section of his ear.

The rage, so intense and so near the surface, is often directed at the borderline’s closest relationships—spouse, children, parents. Borderline anger may represent a cry for help, a testing of devotion, or a fear of intimacy—whatever the underlying factors, it pushes away those whom the borderline needs most. The spouse, friend, lover, or family member who sticks around despite these assaults may be very patient and understanding, or, sometimes, very disturbed himself. In the face of these eruptions, empathy is difficult and the relation must draw on every resource at hand in order to cope (see chapter 5).

The rage often carries over to the therapeutic setting, where psychiatrists and other mental health professionals become the target. Carrie, for example, often raged against her therapist, constantly looking for ways to test his commitment to staying with her in therapy. Treatment becomes precarious in this situation (see chapter 7), and many therapists have been forced to drop borderline patients for this reason. Most therapists will, whenever possible, try to limit the number of borderline patients they treat.

Sometimes I Act Crazy

Criterion 9. Transient, stress-related paranoid thoughts or symptoms of severe dissociation.

The most common psychotic experiences for the borderline involve feelings of unreality and paranoid delusions. Unreality feelings involve dissociation from usual perceptions. The individual or those around her feel unreal. Some borderlines experience a kind of internal splitting, in which they feel different aspects of their personality emerge in different situations. Distorted perceptions can involve any of the five senses.

The borderline may become transiently psychotic when confronted with stressful situations (such as feeling abandoned) or placed in very unstructured surroundings. For example, therapists have observed episodes of psychosis during classical psychoanalysis, which relies heavily on free association and uncovering past trauma in an unstructured setting. Psychosis may also be stimulated by illicit drug use. Unlike patients with psychotic illnesses, such as schizophrenia mania, psychotic depression, or organic/ drug illnesses, borderline psychosis is usually of shorter duration and perceived as more acutely frightening to the patient and extremely different from his ordinary experience. And yet, to the outside world, the presentation of psychosis in BPD may be indistinguishable, in the acute form, from the psychotic experiences of these other illnesses. The main difference is duration: within hours or days the breaks with reality may disappear, as the borderline recalibrates to usual functioning, unlike other forms of psychosis.

The Borderline Mosaic

BPD is clearly becoming acknowledged by mental health professionals as one of the more common psychiatric maladies in this country. The professional must be able to recognize the features of BPD to effectively treat large numbers of patients. The layperson must be able to recognize them to better understand those with whom he shares his life.

While digesting this chapter, the astute reader will observe that these symptoms typically interact; they are less like isolated lakes than streams that feed into each other and eventually merge into rivers and then into bays or oceans. They are also interdependent. The deep furrows etched by these floods of emotions inform not only the borderline but also parts of the culture in which he lives. How these markings are formed in the individual and reflected in our society is explored in the next chapters.