Personality Disorders: Coping with the Borderline

Posted on May 17, 2013 in Articles

Personality Disorders: Coping with the Borderline

Author: Patrick Perry

After a busy day at work, Bob was looking forward to a quick shower, light supper, and a concert with his new girlfriend, Amanda. But outside his apartment, he froze. On his door the word “CHEATER” had been spray-painted in large black letters. Embarrassed, he scanned the hallway, quietly unlocked the door, and slipped inside.

“Did anyone see who did this?” Bob asked the superintendent.

“Your neighbor said that she recognized the car in the parking lot,” he answered. “This is the fourth time somebody’s damaged your apartment. Shouldn’t we call the police?”

“No,” Bob said. “I’ll handle it.”

He knew who had been there. It was Jennifer.

When he first met Jennifer at a bookstore, he was immediately attracted to the pretty, outgoing 21-year- old. Their first few months together were fantastic. She always wanted to be with him, calling him two or three times a day at the office just to let him know she was thinking about him. Over time, Bob learned more about Jenny—the early sexual assault she had suffered, a broken home, and the barely visible scars on her wrists from a suicide attempt when she was just 17. She had been through a lot in her short life, yet seemed to survive it well.

When the accounting firm where Bob worked picked up a new client, Bob began working late hours. At first, Jenny understood, was even supportive. But as the weeks passed, she became more demanding, wanting to know why he “wanted” to be away from her and if “another woman” was involved. She telephoned him throughout the day, monitoring his every move. One night after work, he joined old fraternity buddies for a basketball game at the local Y. Jenny unexpectedly showed up. After delivering a barrage of jealous accusations in front of his teammates, she left. Bob thought the flat tire after the game was just a coincidence. On another late night at work, he found her parked alongside him in the garage, and she acted hurt when he questioned her motives.

Jenny’s jealousy and demands continued, and soon Bob realized that something about the relationship just wasn’t right. He decided to break it off. The decision wasn’t mutual. Jenny began showing up at his office, at first begging for another chance. When he refused, she flew into a rage in front of his coworkers. When his appointment book came up missing, he chalked it up to forgetfulness until someone canceled his plane reservations to an important business conference and canceled his doctor’s appointments. A late-night phone call from Jenny resulted in a trip to the emergency room and an all-night suicide vigil. Bob now realized that Jenny needed professional help. But when he spoke with her the next day about therapy, she became furious, blaming her hospitalization on him and men like him. He left, feeling ashamed and for some reason, responsible.

For the next two months. Jenny phoned him at all hours of the night and at the office. She left scathing, often harassing messages on his answering machine. When the office disruptions threatened his job, Bob took out a restraining order against Jenny. Even then, Jenny persisted. On more than one occasion, he saw her peering through restaurant windows or parked outside his apartment building. His mailbox had been tampered with, his tires slashed, an anonymous basket of funeral flowers sent to his office, appointments cancelled, and a defamatory letter sent to his boss. Still, no one would suspect that the pretty, outgoing girl was capable of, much less responsible for, the havoc in his life.

When will it end? Bob thought. Can I take much more of this?


Rage, impulsivity, self-mutilation, guilt, overwhelming fears of abandonment, and volatile relationships— Jenny’s life is a tattered scrapbook of broken relationships, suicide attempts, uncontrollable anger, substance abuse, and violent mood swings. Jenny is a “borderline,” short for someone with borderline personality disorder. Five million Americans fit the profile of the borderline personality disorder (BPD), according to the latest estimate. One moment calm and engaging, the next tempestuous and combative, borderlines bewilder those around them, straining relationships to the breaking point. It is this unpredictability and loss of control that baffles both people who love them and the psychiatric community that treats them. BPD is a mysterious malady of the personality that one psychiatrist defines as “a problem with who you are.”

The case of Susan Smith, the South Carolina mother who murdered her two children by driving her car into a lake with the children left inside, brought national focus on the subject of personality disorders and the frightening consequences that often result when the disorders are left unchecked.

Unlike depression, a disease frequently episodic in nature and which most people can understand and empathize with, BPD is characterized by enduring and persistent ways of behavior and thought. As such, BPD lies in a unique classification of psychiatric illnesses called personality disorders. According to the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSMIV ), a personality type is looked upon as a disorder when the traits, or personal habits, that constitute the personality are inflexible and damaging, causing serious distress or impaired function. The DSM-IV classifications of personality disorders include: borderline. antisocial, paranoid, narcissistic, avoidant, dependent, obsessive-compulsive, and passive-aggressive.

In her book Imbroglio, author Janice M. Cauwels, Ph.D., presents an in-depth look at BPD, exploring the causes and current theories and offering personal histories of patients suffering from the disorder. Dr. Cauwels discovered that many psychiatrists refuse to see these patients because borderlines are seen as provocateurs and expert manipulators. Dr. Cauwels cites a facetious report on BPD patients as “notorious for late-night irrelevant ‘emergency’ phone calls, no common sense, no redeeming qualities, no income, and no health insurance.” The author also noted that one of the supreme ironies in BPD is that borderlines are the neediest people in the world, yet alienate all from whom they crave love.

BPD is the subject of mounting research, innumerable studies, and various theories. While therapists may differ on theory and origin, few would argue with the statement that BPD appears to be one of the most complicated forms of mental illness. The Post interviewed leading researchers and clinicians about this crippling mental disorder that affects not only the borderline patients but all who come into contact with them.

What Is Borderline Personality Disorder?

John W Gunderson. M.D.  is regarded as a leading author on BPD. He is director of psychotherapy and psychosocial research at McLean Hospital in Massachusetts and professor of psychiatry at Harvard Medical School.

Post: How do you describe a borderline personality disorder?

JG: I think of it as a disorder primarily caused by some defect in early attachment that leads to the person searching for some type of protective, nurturing relationship which they feel makes up for what they unfairly did not get in their childhood. It sets in motion a sort of desperate search for some person who will take care of them and stay with them all the time.

Post: When does BPD begin to emerge?

JG: Usually in adolescence, but there’s usually enough turmoil in normal adolescence that you’re not safe identifying those who will have this disorder until it persists or emerges later in life.

Post: Do borderlines usually focus on one individual at a time?

JG: Yes.

Post: Is this individual a love interest or could it be just a friend?

JG: It could be a friend. It could be a teacher. Most borderline patients feel very secure and can function well, as long as they feel they have someone they believe cares about them and is accessible—someone who will he there. We all need to have caring relationships. What’s different here is that the relationship generally evolves around the hope that there will be one person who will be able to provide all that they need. They get very panicky and have very severe, oftentimes behavioral, reactions when they feel that they’re going to be alone. When border- lines feel the threat that somebody needed is going to leave or has lost interest in them, they engage in a lot of angry and manipulative behaviors to prevent the leaving. If they feel that it’s futile and that they don’t have anyone, they may behave in very desperate ways to become engaged with somebody new— promiscuity, substance abuse, fights. These behaviors—the fights and promiscuity—are often because of the disinhibiting influence of alcohol or other drugs that bring them once again into contact with someone with whom they can recreate the illusion of being loved.

Post: Many people remember the disturbing portrait of borderline disorder in the movie Fatal Attraction. What do you think of that movie’s portrayal of a borderline patient?

JG: I think, more typically, borderline patients will become self-destructive as a way of evoking some kind of caretaking protective response from others. That’s how they prevent people from leaving them.

Post: In the movie, the borderline character’s rage grew, eventually leading her to destroy things dear to the man who was the focus of her obsession.

JG: That is a very extreme, dramatic example. Most of the time a borderline patient may start to feel enraged and may have poor control over that rage, and it comes out. It’s usually verbal. These people feel that when they have been angry, they are bad, even though they initially felt anger was justified because they had been cruelly mistreated. It’s usually hard for them to sustain being angry for long. They soon begin to feel they are evil, then turn the anger toward themselves in very self-destructive ways. Self-destructiveness takes the form of not simply trying to kill themselves, but trying to put themselves in a position where their life is at risk and whether they live or not is in the hands of somebody else. If they are saved, as is usually the case, that’s affirmation they are meant to live and deserve to live. If they are not saved, that is an affirmation they are as evil as they thought and deserve to die. They put their lives at risk in a deliberate way where their fate depends upon external intervention.

Post: Could you give a description of how a borderline might react in frustrating situations that all of us encounter—when your car breaks down or you’re stuck in a grocery line? Do they react the same way others do?

JG: Most of the time, yes. But consider a patient, for instance, who learns the night before that her boyfriend is going to move out. If then the next day she goes to a grocery store and a child is crying, she might feel inappropriately enraged at the child—so much so that she envisions very primitive things like cutting the kid’s tongue out. She is frightened of that thought and says to herself, “This is crazy—I’ve got to get out of here,” because borderlines fear they won’t be able to control the anger. She leaves the store. At that point, she hasn’t done her grocery shopping, so she feels ashamed of herself for that. She gets into the car and, in an admixture of frustration and guilt, slams into the car in front of her. Feeling that the car in front of her was going too slow and that this is unfair, she’ll be enraged at the driver and create a big scene.

Post: What do you consider the two principal diagnostic hallmarks of borderline?

JG: Intolerance of aloneness and self-destructiveness.

Post: Many magazine and professional journal articles mention a relationship between sexual abuse and borderline disorder, particularly among female patients. Were the vast majority of borderline patients sexually abused as children?

JG: Yes, that’s well-established, but a ‘vast majority” overstates it. You can safely say that a large percentage of borderline patients have had abusive experiences in their childhood, but abuse is neither necessary nor specific.

Post: You mean it doesn’t matter if the abuse is sexual or if it’s, for example, abandonment?

JG: It matters. But the degree of sexual abuse is linked to the high frequency of females with the disorder. With the antisocial personality, you see a familiar frequency of abuse in their childhood, but it’s less frequently sexual.

Post: How often are borderlines also antisocial?

JG: About 25 percent.

Post: Is having both traits, borderline and antisocial, a particularly dangerous combination?

JG: “Dangerous” is a strong word because it implies that there’s a high risk of violence to other people. I would not say that is the danger, primarily. The problem with the combination of BPD and antisocial disorder is that patients with both these traits are harder to treat and more apt to exploit others without great remorse.

Post: For example?

JG: A babysitter who steals from the employer. They are also, I think, at somewhat higher risk of being irresponsible caretakers. Violence in borderline patients is largely impulsive and under extreme circumstances. It’s not something that recurs very often because it’s usually followed by intense and suicidal self-accusations. That doesn’t mean that such people are not capable of violence. That woman who drowned her children, for example.

Post: Susan Smith, the South Carolina mother who drove her two young children into a lake in a locked car and watched them drown?

JG: Yes. Chances of BPD are quite high in a number of such cases in the news where women have done very violent things to their kids. But that’s a little different from antisocial as a recurrent pattern of disregard for social norms and the feelings of others.

Post: When I hear the term borderline, it’s often associated with violence, as in the case of Susan Smith. Are cases like this exceptions to the rule when it comes to borderline personalities?

JG: Yes. Violence is usually an act of passion. It’s done impulsively under the overriding influence of strong feelings and poor control over impulses. A repeated pattern of systematically being sadistic to others is not typical of borderline patients. It can happen, but that’s not typical. Sadism would be much more likely in a purely antisocial person. Someone who really doesn’t have any regard for the rights and feelings of others – that isn’t typical of borderlines.

Post: In what you’ve read about Susan Smith’s history, what led you to label her a borderline personality?

JG: I didn’t read very much of the story, so I may he in error. But borderlines have a tremendous dilemma once they become mothers, because an overriding fact of their lives is that they feel that they did not get adequate mothering. That doesn’t mean it’s true, but that’s a very important and central part of their motivations and self-esteem. So they often dream and believe that the highest calling on earth is to become a mother—and a good mother. The problem is, they’re psychologically handicapped. Are you a father?

Post: Yes.

Parenting is very difficult for those with borderline personality disorder. The nation was stunned as Susan Smith confessed to the murders of her two preschool children, yet with a history of suicide attempts, failed relationships, promiscuity, and early sexual abuse, Susan Smith fit the profile of borderline personality disorder. Accusing others for their own misdeeds is a typical borderline response. Ironically, in a letter from jail to her grieving ex-husband, father of the two children, Smith complained that her feelings were getting lost, writing, “Nobody gives a damn about me.”

JG: You probably know, then, that one’s little blighters don’t always behave. In fact, they disregard what you tell them to do repeatedly. It takes a lot of sustained limit-setting and frustration tolerance to keep your caretaking role in line, in the face of what could be extremely frustrating circumstances. This overwhelms mothers who are borderline in a variety of ways. One is that the amount of care and attention children legitimately require can tax anybody. But for these women, it’s accompanied by a feeling that they themselves are being deprived. It opens up to them how much they aren’t getting. In fact, they are giving all the time: it is a depriving stance for everybody. But borderlines feel an enormous sense of deprivation when remaining in this stance for sustained periods of time. In addition, they can’t get angry at the little blighters without feeling that they are as bad as. or the embodiment of, the evil mother they hated and renounced. That leads to suicide, because nothing is worse. Susan Smith, as I recall, felt herself to be in a bind where her hoped-for savior—the boyfriend—and his continued availability to her were dependent upon getting rid of the kids. So she sacrificed them—but then couldn’t live with herself.

Post: Do borderline patients generally make good mothers?

JG: No, but not for a lack of wanting to. Borderline mothers don’t have the psychological resources to manage the feelings normal mothers require in terms of the ability to satisfy personal needs and the ability to get angry in some kind of modulated, controlled, reasonable way—at least without feeling they’ll lose control over the anger and do something violent, which they can do. But then they feel terrible about it, often withdrawing from their roles as mothers once it’s happened.

Post: How do they withdraw?

JG: They will try to turn the primary care of the child over to someone else. They’ll become chronic psychiatric patients. I’ve known a number of borderline women who found refuge in a psychiatric career because it gave a sort of legitimacy to their inability to mother. They could come back and spend shorter periods of time with the children without being overwhelmed, but they weren’t expected to be there all the time. Sometimes they can arrange for someone else to take care of the children. These mothers have some strengths. They may be able to get employment so that they can help with the support in a responsible way, but away from some of the immediate emotional demands.

Post: Is the therapy used to treat borderlines primarily psychodynamic?

JG: I’m primarily psychodynamically oriented, hut I have a strong conviction that individual psychodynamic therapy is not usually sufficient for such patients and that you need to integrate psychodynamic therapy with social therapies, like group and family work.

Post: If volatile, unstable relationships are characteristic of borderline people, do they generally end up alone?

JG: Borderline patients usually go from one intense relationship to another. It’s the very intensity of their needs that usually makes relationships short-lived. Borderline patients do learn from experience, however. By the time many of them reach their 30s, they will either have modified their interpersonal behaviors enough to sustain relationships, or they will have gone into a more withdrawn situation where they try to avoid getting too involved with people. Instead they try to get their needs met by quite superficial involvements with lots of people. Involvement in self-help groups, churches, or employment situations provide sufficient social contact for them, but they don’t get too close to anyone. That’s one outcome.

A minority of borderline patients actually improve enough so that they can develop quite reasonably stable, and even relatively healthy, relationships. Those are people who usually have had a corrective relationship somewhere along the line, where they have gotten involved with someone over a long period of time and have become more comfortable with their feelings. Because their self-images have changed, they are less apt to feel that they are had people. That can happen in the course of a good long-term therapy. Sometimes it may even happen, although I think not quite as completely, through the provision of a good relationship in the outside world.

Post: The Post featured an article on bipolar disorder in its March/April 1996 issue. We spoke with Dr. Kay Redfield Jamison, whose books examined a relationship between bipolar disease and creativity. What emerged was a roster of famous people who were highly creative. Are borderline patients also politicians, business leaders, mayors, teachers -of-the-year?

JG: That would be quite unusual, although Marilyn Monroe was probably borderline. Her whole life was tempestuous and maybe more typical of a borderline patient’s life. Even when they have done something creative, they are likely to be embedded in a very inconsistent record of productivity, as well as involved in many tumultuous relationships. They would not make for good schoolteachers.

Post: Are borderlines masters at manipulation?

JG: Yes. Some more than others.

Post: Is that why therapists are reluctant to treat borderlines?

JG: Once again, I think it has less to do with their fears about the borderline patient actually hurting them in any physical way, but it may have to do with their apprehensions about being manipulated. Most therapists like to think the best about people, and so they’re vulnerable to that kind of thing. But most often the apprehension will have more to do with their borderline patients’ fears of abandonment and their inability to be alone. The therapist often expects to be disrupted frequently in the middle of the night. Or that patients will want to go with them on vacation, be extremely jealous of the therapist’s children, or park out in front of the yard. Those are the most common concerns of therapists.

Diagnosis and Treatment of BPD

BPD researcher, clinician, and author of the book Borderline Personality Disorder: A Multidimensional Approach, Joel Paris, MD., is senior psychiatrist. Institute of Community and Family Psvchiatry, Sir Mortimer B. Davis-Jewish General Hospital, and professor of psychiatry at McGill University. Montreal.

Post: How does BPD differ from other personality disorders?

JP: There are ten categories of personality disorder, of which borderline has been the subject of the most research. Borderline personality refers to people who can best be described as emotionally unstable in an extreme way. They tend to have many problems of a particular kind in their relationships. They get involved with other people quickly, but things also sour very quickly. They’re impulsive in a number of ways, many of which are related to suicide.

The most characteristic feature of the condition is multiple suicide attempts. These attempts usually occur in the context of a problem in a relationship. These patients come into the emergency room, for example, after a fight with somebody, which leads them to take an overdose or to slash their wrists.

Post: One therapist said that he could diagnose a borderline personality in ten minutes. Are they difficult to diagnose?

JP: I can sometimes do it in ten minutes, but you may miss something. There is a feel about these people. For example, a patient that I saw this morning was dysphoric [depressed], miserable, angry, on edge. and impulsive: she couldn’t stand how she felt. She immediately engaged me in a very complicated and unpleasant interaction.

Post: Wouldn’t most people be initially hesitant with a stranger?

JP: That’s right. Borderlines don’t have very good boundaries. When most people see a psychiatrist, they open up slowly. Borderlines will give you deep stuff in minutes—which also makes you think about a borderline diagnosis.

Post: Are borderline personalities resistant to change?

JP: Resistant to change by definition, because all personality disorders are chronic and resistant to change over time. That is how they are defined.

Usually, borderline personalities are very demanding of therapy. The irony is, and this has been shown in research, that if you offer borderlines psychotherapy, about two thirds of them will drop out within a few months—another measure of their impulsivity and emotional instability. In other words, they get frustrated with the therapist. They might say to the therapist, “You’re not helping me. You don’t care,” then storm out.

Post: What brings them to therapy in the first place?

JP: Suicide attempts or suicidal feelings are typical.

Post: Are pharmacological interventions successful?

JP: Borderlines don’t respond to drugs very well, even though most of them are on medication. At this point in time, pharmacological treatment doesn’t last long and is not very impressive. If I give Prozac to somebody with a classic depression, it’s almost like magic. The patient often feels like a new person in a few weeks. But if I give borderline patients Prozac, they might feel a little better, yet in a few weeks we’ll be back to square one. Although drugs are given to many of these patients, we haven’t discovered or haven’t invented the right one yet.

Post: In your book Borderline Personality Disorder, you mentioned abnormally low levels of serotonin—a neurotransmitter affecting mood and behavior in the brain.

JP: Yes, that’s a theory. There is indirect evidence supporting it. While it a subject of intense research, I don’t think neurotransmitters fully explain disorder. If they were just deficient serotonin, why don’t they get better Prozac?

Post: What about psychotherapy?

JP: This is a very interesting story. The term “borderline” was first used the 1930s by an analyst who hypothesized that the reason these people don’t get better is they are on the borderline of psychosis and neurosis. We stuck with that term, even though we don’t believe in the theory anymore. At the time, this analyst wrote that these people don’t respond well to analysis. I think almost everyone since agrees. Nevertheless, a lot of psychotherapists have tried to use modified versions of psychoanalysis, so-called psychoanalytic therapies, with these patients. The problem is that there is no scientific evidence showing whether the therapies do or don’t work.

What I wrote in my book was my own clinical experience, using therapy successfully in subgroup classes with high-functioning borderline patients— people, for example, who have good jobs or are attending a university, but whose personal lives are a mess. A lot of studies show that the better functioning you are, the more you get out of psychotherapy. If you are not functioning well anywhere in your life— are on welfare and have few friends— you tend not to do well in psychotherapy. The problem is that a lot of borderline patients are on welfare and also have many problems maintaining friendships.

Post: Structured environments seem to work best for these people?

JP: That is one of the main points in my book. Of course, they’ve got to have the ability to get into a structured environment. I work part-time in the McGill University health service, so a number of the cases I described were university students. Obviously, these are people who are able to structure themselves. They have higher IQs or other positive personality traits.

I also said in the book that modem society, where it’s every man and woman for themselves and where there is such a high level of individualism, might be one factor making BPD more common.

Post: How would a lay person recognize these symptoms’?

JP: It’s not easy. When you are a psychiatrist, people tell you everything. You discover that you know your patients better than you know your friends. However, many people know someone who is chronically suicidal and has had many treatments for suicidal threats or attempts, usually involving overdoses or wrist cuttings. Attempted suicide is the most characteristic symptom of the disorder.

Post: If people have seven of the nine diagnostic criteria for BPD but lack the suicidal trait, would they fall outside the diagnosis?

JP: No. If you have seven of the nine, you fit the profile. The way the DS1M-IV is written, all nine have an equal weight, hut they are not independent of each other. But I’ve never seen anyone who has met the criteria yet who didn’t at least have some suicidal behavior.

Post: Is life with a borderline patient challenging?

JP: When you’re the therapist, you start feeling that you must be a terrible therapist to have somebody hate you or telling you such things as “I’m going to kill myself, and it’s your fault, Doctor.” I like these patients very much who, with all of their pathology, can be quite engaging, but they are very good at making other people feel sorry for them, guilty about them, and that people close to them haven’t done enough to help. Friends and family should distinguish between empathy and sympathy. Empathy doesn’t necessarily mean that you agree with the person’s actions. There are times when a therapist has to say, “Well, you could kill yourself, but I would rather see you next week for the session.”

Where other people in the life of borderline patients can go wrong is by trying to do too much. The borderline patient is asking you to be mother, father, lover—everything. People might think, Gee, this person really needs me . . . I can understand her better than anyone else. But after a while, the person gets mad at you, and you’re caught.

Post: In your book, you write that the disease is self-limiting.

JP: That is what is called “burnout.” Time wears the pathology down. That is true also of antisocial behavior and drug abuse.

The Prevalence of Childhood Sexual Abuse

Paul Soloff, M.D., professor of psychiatry at the University of Pittsburgh, Western Psychiatric Institute and Clinic, is a leading researcher in the psychopharmacology, as well as psychobiology, of BPD.

Post: Is childhood abuse implicated in the incidence of borderline personality disorder?

PS: More recently, the literature has indicated high incidence of abuse— physical abuse or sexual abuse—in the histories of patients with borderline personality disorder. Not all, but many. Some of the percentages are as low as 20 percent, others as high as 70 percent, but always more than in control groups. So the sexual-physical trauma contributes to that interpersonal style of functioning that involves manipulative, dependent relationships. The patients have a chronic low sense of self-esteem, feel bad about themselves, feel like nobody could care for them.

Post: When do borderline patients most often come to the attention of the psychiatric community?

PS: Borderline patients most often come to our attention at times of crisis, usually in the face of a perceived rejection. I use the term ‘rejection sensitivity.” That’s one of the buzz words for the mood crashes, the depressive episodes that they have. At a time of perceived rejection, these are the patients who take pills on impulse, cut themselves, or burn themselves. When we see them, they are often in an emergency room with lacerated arms or an overdose of pills. When taking a patient’s history, we discover there’s a track record and that the patient may have done it many times before.

Post: Self-mutilation could take many forms, is that correct?

PS: Yes, it does, actually. The most common is wrist- cutting or burning with cigarettes. Part of what happens is that these patients usually use the Cut or the burn. It has several meanings. One meaning is that the wrist cut or the burn deals with some intense feeling the patient is having. That’s its primary purpose—to deal with some intense feeling. In psychiatry, we call that the primary gain. The symptom is doing something for the patient within himself or herself. It’s handling this very strong feeling. But in psychiatry we also recognize that symptoms have a personal value to others—an interpersonal meaning. This is called the secondary gain. Now that’s fairly easy to understand, because if you cut your wrist and you show it to somebody, what happens? Right away people pay attention. They either put you in the hospital, take care of you, nurture you, or criticize you, but you get a tremendous amount of attention. That’s what happens with a borderline patient. Typically, you have a person who, feeling abandoned or alone, does something to himself to deal with that intense feeling. That’s the primary gain. The secondary gain is that the patient usually makes sure that somebody else knows about it— the police, the family, or the doctors arrive. The person is the focus of attention. Think of these destructive actions as primitive efforts to obtain help, to force other people to take care of this person—that’s a typical kind of borderline dynamic.

Post: Do borderline personalities want therapy?

PS: Patients want therapy. In fact, they’re among our most demanding patients because these are people who are seeking care. They manipulate care. They force others to take care of them. That’s not the problem. The problem is the forms of treatment that we have so far are not very good. The medications that we have help to palliate the impulsivity and the mood disorder, the mood disregulation. The psychotherapies are in no way curative; they are primarily supportive. You don’t cure personality disorders. You help people deal with the symptoms and vulnerabilities that they have. You help them live better.

Post: What’s it like to live with a borderline?

PS: I have not had that experience, but my patients certainly have, and I have talked to their spouses. Border- lines are very unstable and argumentative. A family disagreement can result in a trip to the emergency room with her overdosing or his smashing the windows. They’re unpredictable in that sense. Borderlines are very rejection-sensitive, so that things you and I would take for granted—criticism, for example—a borderline patient might see as a rejection. Or a partner coming home late for dinner might be taken as rejection. It’s the quality of feeling rejected that is important. Abandoned, rejected, that’s the critical element here,

Post: Why do you think that three quarters of BPDs are women?

PS: That is part of cultural bias. In this country, three quarters of them are women. In general, that’s not true in other countries. There are cultural ways of expressing distress. In this culture, women are taught to express stress by turning their aggression against themselves; men are taught to channel their aggression against others. Men do things that are very dramatic. Male borderlines would, for example, get into fights, stand on bridges, use handguns, create a disturbance—they’ll usually end up in jail. Women will end up in mental hospitals: they cut themselves, they burn themselves, they take overdoses. So, the first thing we have to contend with is the cultural bias in symptom expression. What I am saying is that you can have exactly the same problem and, if you’re a male, you do something dramatic; you won’t cut your wrist. I had one patient who would punch policemen. Another would break picture windows in downtown department stores in broad daylight—smash windows one right after the other. They ended up in jail. They have exactly the same psychodynamic motivation as a woman who might take a handful of pills or cut her wrists when she’s feeling rejected. So cultural expression of symptoms is a big part of it.

Comments by Janice M Cauwels, Ph.D., writer, consultant, and author of Imbroglio

Post: What was the predominant feature of BPD you encountered in interviews with experts?

JC: The key feature of BPD to experts is that it is the most difficult psychiatric illness to treat. Physicians in other specialties don’t like border- lines, either. While writing my book, for example, I mentioned the topic to a resident in allergy and immunology who had worked for a while in an emergency room. She launched into a tirade against the suicidal border- lines who had appeared or been brought in for treatment while she was on duty, apparently because they had been demanding and troublesome.

Borderlines appear to be very capricious and manipulative. They want to foist all their own responsibility for getting better onto their therapists, with whom they become intensely involved, yet they often reject therapists’ efforts to help.

Even competent therapists can become so emotionally involved with borderline patients, in turn, that they feel tossed around and make terrible mistakes in treatment. For this reason, knowledgeable therapists insist that ongoing consultation with a colleague about a borderline patient’s case is always necessary. But even with such assistance, no experienced therapist treats more than one or two border- lines at a time in private practice.

I observed a class on personality disorders in which several psychiatric residents explained that they disliked dealing with borderline instability, dishonesty. distortions, brief psychotic episodes, unbearable anger, demands, and constant threats of suicide. These residents felt scapegoated by the hospital staff for having such troublesome patients.

Writing Imbroglio was frustrating because of both the complexity of the subject matter and the objections of therapists to the forthcoming book. Most therapists believed that I had set myself an impossible task; some predicted that I would become a target of borderline rage; many, I think, feared that information about the illness would make their work more difficult by getting borderline patients all stirred up.

Diagnostic Criteria for Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Frantic efforts to avoid real or imagined abandonment.
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  5. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Source: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV TM)

Are you coping with someone who has Borderline Personality Disorder?

Do you find yourself:

  • Concealing what you really think or feel because you’re afraid of the other person’s reaction, and it just doesn’t seem worth the horrible fight or hurt feelings that will surely follow? Has this become so automatic that you have a hard time even identifying what you think or feel?
  • Feeling like you’re walking on egg- shells much of the time, and that no matter what you say or do, it will be twisted and used against you?
  • Being blamed and criticized for everything wrong in the relationship, even when it makes no logical sense?
  • Being the focus of intense, even violent rages that make no logical sense, alternating with periods when the other person acts perfectly normal and loving?
  • Feeling like you’re being manipulated, controlled, or even lied to sometimes?
  • Feeling like the person you care about sees you as either all good or all bad, with nothing in between? Wishing that the person would act like they used to, when they seemed to love you and think you were perfect and everything was wonderful?
  • Feeling like the other person is like “Dr. Jekyll and Mr. Hyde”: one moment a loving, caring person; another moment someone who seems so vicious you barely recognize them? Wondering which one is “real”? Hoping that it’s a phase that will go away—but it doesn’t? Feeling like you’re on an emotional roller coaster with high highs (things are incredible, fantastic) and very low lows (feelings of despair, depression, grief for the relationship you thought you had)?
  • Being afraid to ask for things in the relationship, because you will be told you’re too demanding or there is something wrong with you? Being told that your needs are wrong or not important?
  • Wondering if you’re losing your grip on reality because the other person is always putting down or denying your point of view? Plus, the other person often acts just fine in front of other people, so no one believes you when you explain what’s going on?
  • Feeling that nothing you do is ever right, and when you do manage to do what the other person wants, suddenly they change their expectations? The rules keep changing, and no matter what you do, you can’t win? Feeling helpless and trapped?
  • Being accused of doing things you never did and saying things you never said? Feeling misunderstood a great deal of the time, and when you try to explain, the other person doesn’t believe you?
  • Being constantly put down, yet when you try to leave the relationship, the other person tries to prevent you from leaving in a variety of ways—anything from declarations of love and promises to change to outright implicit or explicit threats such as “you’ll never see the children again” and “no one but me will ever love you”?
  • Having a hard time planning anything (social engagement, etc.) because of the other person’s moodiness, impulsiveness, or unpredictability? Sometimes, even making excuses for their behavior to other people—or trying to convince yourself that this is normal behavior?
  • Reading the above list and thinking, I had no idea that other people were going through the same thing and that there is a name for this: Borderline Personality Disorder?

From BPD Central, an Internet resource for people who care about someone with borderline personality disorder. BPD Central is a three-star site of Mental Health Net (
Internet Address for BPES Central: http:// members aol. com/BPDCentral.
Copyright © 1996, Paul Mason, MS, and Randi Kreger. All rights reserved.

“Walking On Eggshells

Health writer Randi Kreger first became interested in borderline personality disorder when someone close to her was diagnosed with the disorder. After researching the available literature, she discovered that insufficient support information was available to the borderline’s family and friends coping with the chaos caused by the person with borderline personality disorder.

Enter the Internet. Kreger began conversing via e-mail with borderline patients, their families and friends. With the help of volunteers she met on the Internet, Kreger initiated a World Wide Web site with information about BPD and organized an e-mail support group for non-BPs—a meeting place dedicated to their needs. The response has been overwhelming. Hundreds of letters from grandmothers, children, and borderline patients started pouring in.

“The most anguished letters came from non-BP parents—usually fathers— concerned about emotional abuse of their children by a borderline partner,” Kreger noted. “These men felt thwarted by judges and social-service systems that considered mothers essential and fathers optional, and that deemed even severe verbal abuse to be unproven at best, irrelevant at worst.”

A sampling of these letters follows:

“Over the years (almost 15), I’ve often complained of her Jekyll and Hyde personality, sharp and abusive tongue, negativism and pessimism, blaming, public putdowns, and ‘jokes’ about me. I’ve been seeing a counselor for almost a year since my wife left. He suggested that she suffers from BPD. She took a ‘scorch the earth’ stance on a divorce and in a very short time went through my life savings. I came home to an empty house. She is an expert at turning situations and statements around to create the picture of herself as the victim. She is now 1,500 miles away with my teenage sons. I have been ruined financially and emotionally, and I live in constant fear for my kids, I have seen this woman fluctuate from passive to extremely agitated, beating our child. She seems to have no problem just making things up out of the blue, and the judge believed or protected her. She got custody.” – Daniel

“Things kept getting worse, and nothing I did seemed to help. In fact, the more I did, the worse things got. When I finally filed for divorce in 1995, all hell broke loose. She became a more bitter, vindictive, and hurtful person than t could have imagined. She used every dirty trick and pushed every hot button there was. I filed domestic abuse charges twice. . . . I have always provided daily care, emotional support, and love to our children. Yet in the custody trial, she portrayed me as an unreliable, immoral, and absentee father. I was stunned. . . . I tried to defend myself, but it was just as though I never said anything at all. The judge said that I did not provide sufficient evidence to convince her that she was an unfit mother and gave my ex-wife sole physical custody, despite the explicit preferences of all three of our daughters and the recommendation of a court-appointed psychologist.” – Michael

 “My wife spent the first part of the morning baiting me for a fight. When this failed to generate a sympathetic response from me, she started threatening suicide in front of our ten-year-old daughter. She then attempted to set off for parts unknown (after vowing to end it all) with our three-year-old daughter in her arms. When I said that I’d call the police, she put her down and attacked me in a rage. . . . I had already decided to cut my losses, protect the kids, and get out of the relationship.” – Peter

And there were hundreds more.

In Walking on Eggshells, Randi Kreger, with psychotherapist Paul Mason wrote a simple, easy-to-read booklet, based on interviews with more than 400 people with BPD and their loved ones. They also interviewed more than two dozen top BPD therapists to determine how people who care about someone with BPD can cope with the disorder— even if the person with BPD won’t seek change. The booklet is drawn from the authors’ new book on BPD, to be published by New Harbinger Publication in spring 1998.

“We wrote Walking on Eggshells to help family members and friends better understand how borderline personality disorder affects their loved ones,” said Kreger, “and what they can do. step by step. to get off the emotional roller coaster while remaining supportive and caring of the person they care about.”

Walking on Eggshells may be ordered by calling 1-800-266-5564 (or 1-414-635-5527). Free information about BPD is available through the BPD Central World Wide Web site,