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Diagnosing
Borderline
Disorders
by
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Louis A. Moench, M.D.*
Presented at the AMCAP convention
October 3, 1980 |
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The physician's dictum is "primum
non nocere" first, do no harm. Dr. Allen Bergin is noted for his
research showing that psychotherapy in some instances harms the
patient or worsens his condition. Dr. Bergin's concern in
assigning me this presentation is that we as therapists need to
know something of how to recognize and understand the prime
candidates for getting worse in improper therapy. |
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Little about the therapy of
these patients will be discussed since it can't be learned from
a lecture. Those not familiar with it should refer to the most
experienced therapist they know. Even he will be challenged. |
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Let us clarify which patients we
are talking about. Most therapists have been baffled by certain
patients who seem to show symptoms of several neuroses,
sometimes all at once, and at times psychosis as well. For
patients hovering on these borders between categories, various
diagnostic terms have been used, the most enduring of which has
been, not surprisingly, "borderline."
The term evokes images of someone precariously balancing on a
fence between neurosis and psychosis. A more accurately
descriptive image may be that of the traffic of one's various
ego functions running back and forth between personality
integration and disintegration. It is usually rush hour where
these patients' psyches reside. |
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Helene Deutsch (1942) was struck
by a depersonalization aspect to these people and described them
with the term "as if personalities," meaning that they behaved
as if they had a personality to rely on when they, themselves,
most commonly complained of being devoid of personality, i.e.
"so empty inside." The external shell, like the skin of a
chameleon, would change, adapting itself to the environment at
any given moment, imitating, conforming, being someone this
morning, someone different this afternoon, lacking the substance
inside to know how to be amid the changing scenery. |
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Paul Hoch and Philip Polatin
(1949) wrote of these patients' multiple neurotic
symptoms—depressions, compulsions, obsessions, emotional
outbursts, hypochondriasis—and their anxieties, chronic and
unattached to any specific fear situation. The equator, for
example, may make such a patient nervous. Hoch and Polatin
described pan-neurosis and pan-anxiety. They saw relationships
with others as intense, unstable, and fleeting, particularly the
most intimate of relationships, the sexual one. Any combination
of deviance, in short, polymorphous perverse sexuality often
characterizes the
borderline. |
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Melitta Schmideberg (1947),
daughter of Melanie Klein, observed that these people were found
not only on the borderlands of psychosis and neurosis, but also
of psychopathy and even normalcy, using defenses appropriate to
any of these, and at times appearing very stable. |
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Robert Knight (1953) clarified
that the term didn't always reflect the confusion of the
patient. Sometimes it reflected the uncertainity of the
psychiatrist.
Borderline was the diagnosis for everyone who perplexed
us. Not just a waste basket, it was the whole city dump! He
advised us that the symptoms do not make the diagnosis, rather
ego weaknesses do. He described macroscopic ego weakness similar
to those to be discussed later, and microscopic ones consisting
of various types of thought disorder and speech peculiarities,
the patient's having no discomfort over their awareness. |
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We are all constantly confronted
with problems, and how we handle them determines the label
applied to us. Roy Grinker (1969) found four labels to
characterize according to ego function sub-types of the
borderline syndrome. (Figure 1) Features he found |
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Figure 1.—GRINKER
CRITERIA FOR THE
BORDERLINE SYNDROME |
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A. Psychotic Border
1. Inappropriate, nonadaptive behavior
2. Deficient self-identity and reality sense
3. Negative behavior and anger
4. Depression |
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B. Core
Borderline
1. Vacillating involvement with others
2. Anger acted out
3. Depression
4. Self-identity inconsistent |
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C. As-if Person
1. Behavior adaptive, appropriate
2. Complimentary relationships
3. Lack of affect and spontaneity
4. Defenses of withdrawal and intellectualization. |
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D. Border With Neuroses
1. Anaclitic depression
2. Anxiety
3. Resemblance to neurotic, narcissistic character |
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[p.5]
common to all four types included these: 1. Anger as the main or
only affect. 2. Defective affectional relationships. 3. Absence
of firm self-identity. 4. Depressive loneliness. |
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Whether it is a state, a
personality disorder, a type of personality organization, or a
pseudoneurosis is debated. One therapist even claims, with
incredible redundancy, the existence of a "pseudo-as-if"
condition. There is disagreement that "borderline"
as a diagnostic category should exist at all. |
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Perry and Klerman (1978),
Spitzer (1979), and Gunderson and Kolb (1978) have all done
confirmatory studies validating the diagnosis. It has been
included in the DSM III with these diagnostic criteria. (Figure
2). |
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Figure 2.—DSM III
CRITERIA FOR
BORDERLINE PERSONALITY DISORDER |
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1. Impulsivity and
unpredictability in at least two self-damaging areas, e.g.,
spending, gambling, substance abuse, overeating, shoplifting,
sex. |
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2. Unstable and intense
interpersonal relationships, e.g., marked shifts in attitude
toward others, idealizing, devaluing, or manipulating others for
one's own ends. |
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3. Inappropriate, intense,
or uncontrolled anger. |
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4. Identity disturbances
manifested by uncertainty about self-image, gender identity,
goals, career choice, friendship patterns, values, loyalties. |
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5. Affective instability
with marked shifts of a few hours to a few days from normal mood
to depression, irritability, or anxiety. |
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6. Intolerance of being
alone, e.g., depression when alone or frantic efforts to avoid
being alone. |
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7. Physically self-damaging
acts, e.g., suicidal gestures, self-mutilation, recurrent
accidents or physical fights. |
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8. Chronic feelings of
emptiness or boredom. |
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(At least five of these must be
present. If under 18, does not meet criteria for Identity
Disorder.) |
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The term "borderline"
is also used in another way. It describes a
schizophrenia-like disorder, not clearly schizophrenia,
mentioned by Kety, Rosenthai, and Wender (now of the University
of Utah) in the classic study of schizophrenia in adopted-away
offspring of schizophrenic parents. (It was this study that
prompted Kety to respond to Thomas Szasz, "If schizophrenia is a
myth, it's a myth with a high genetic component!") Eight factors
used by these researchers to spot schizophrenia-like conditions
which were not schizophrenia have also proved reliably to single
out the disorder among other types of illness. Similar but not
identical to
borderline personality criteria, these features diagnose
another DSM—III category, "schizotypal personality disorder"
(Figure 3). |
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To understand what leads these
patients to think, feel, and behave as described by these
criteria, we turn to the master theoretician, Otto Kernberg, who
is not only brilliant, but awesome in his command of
psychoanalytic cliche and close to impossible for mere mortals
to comprehend. What follows is an attempt to decipher Kernberg. |
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Kernberg says first that reality
testing is generally maintained in
borderline patients except for transient psychosis
precipitated by either severe stress, alcohol or drug use, or
psychoanalytic transference. This response to the unstructured
situation of analytically- |
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Figure 3.—DSM III
CRITERIA FOR SCHIZOTYPAL PERSONALITY DISORDER |
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1. Magical thinking, e.g.,
superstitioushess, clairvoyance, telepathy, "sixth sense,"
bizarre fantasies or preoccupations. |
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2. Ideas of reference. |
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3. Social isolation, e.g.,
no close friends, contacts limited to everyday tasks. |
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4. Recurrent illusions,
depersonalization, derealization, sensing presence of a person
or force not actually present. |
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5. Odd speech (without
derailment), e.g., digression, vagueness, overelaboration,
circumstantiality, metaphorical speech. |
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6. Inadequate face-to-face
rapport due to inappropriate or constricted affect, e.g.,
aloofness, coldness. |
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7. Suspicion or paranoid
ideation. |
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8. Undue social anxiety or
hypersensitivity to real or imagined criticism. |
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(These characterize long-term
functioning, not just episodes of illness. Does not meet
criteria for Schizophrenia.) |
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oriented psychotherapy is the
prime reason for these patients' frequently becoming worse in
treatment. They are candidates for trials for the most skilled
of therapists. |
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Kernberg clarifies the symptoms
and character types further. The anxiety is free-floating. The
neurotic picture is polysymptomatic and unusual. For example,
phobias are multiple and not related to external objects so much
as to the body, e.g. fear of talking, of blushing, or of being
looked at, or to transitional elements such as dirt and
contamination, or to social situations with paranoid elements to
the fear. The obsessions and compulsions are egosyntonic. True,
one wants to rid himself of them, but one also rationalizes
them. Hypochondriasis in these patients isn't of an anxious
nature, e.g. cardiac palpitations, so much as health ritual or
withdrawal from social life to concentrate on health. Conversion
reactions are multiple, elaborate, and bizarre, e.g. bodily
hallucinations. For example, a patient of mine described mucus
draining from her sinuses down a channel she could feel in the
right side of her throat, down into her chest cavity where the
mucus "fumed" out an imaginary hole in the wall of her chest.
Dissociations such as fugue, amnesia, twilight states, sixth
senses, telepathic feelings, and supernatural communications or
transportations are common, and can, among L.D.S. people, easily
be mistaken for revelatory experience. Sexuality, polymorphous
and perverse, commonly takes the form not of fixed and stable
deviations but bizarre combinations, for example erotic pleasure
from eliminatory rather than genital aims, homosexuality
together with heterosexual exhibitionism, or asexual behavior
but bizarre sadomasochistic fantasies. |
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Prepsychotic personality styles
are often evident,
[p.6] including paranoid,
schizoid, hypomanic, or cyclothymic types. These may actually be
variations of affective
disorders, for example rapid-cycling manic depressives
and the phobic-anxious or hysteroid-dysphoric atypical
depressive syndromes described by Donald Klein. Impulse neuroses
and substance abuse or addiction are frequently found. |
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Characteristically, the
impulsive behavior is ego-dystonic most of the time but
pleasurable and welcome during its actual repetitive eruptions.
Much sexual promiscuity falls into this category and perhaps can
be understood better as failure of impulse control than as sin
through willful disregard of commandments. Infantile,
narcissistic, antisocial, and depressive-masochistic character
disorders also fall within the
borderline personality category. |
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What underlies these symptoms
and categories, according to Kernberg, is a weakened ego (Figure
4). He finds these signs of ego weakness present: 1. Diminished
anxiety tolerence. Not the degree of anxiety felt but the mode
of handling increased anxiety is what is important.
Borderline patients handle increased anxiety loads with
movement toward ego regression. 2. Poor impulse control. This is
an erratic and unpredictable effort to disperse tension, unlike
repetitive, specific diminished control such as may be found in
a habit disorder or a quick temper. 3. Diminished development of
sublimatory channels.
Borderline personalities lack the creative enjoyment and
achievement commensurate with their intelligence and social
environment. |
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Kernberg describes a shift
toward primary process or nonlogical thinking. This is only
subtly present under normal conditions but may become florid in
nonstructured circumstances. For this reason, projective
psychological testing is extremely helpful in making the
diagnosis. Primitive fantasies, peculiar verbalizations, and
poor compliance to the "givens" of the test are expected. |
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Specific defensive operations
are employed. To understand these requires a review of ego
development for which Margaret Mahler's model is useful (Figure
5). |
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During the stage of primary
autism, the first two months of life, a child has no capacity to
distinguish himself from his world. He, his mother, and the
objects in the room are all parts of the same whole. The mere |
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Figure 4.—KERNBERG
CRITERIA FOR
BORDERLINE PERSONALITY ORGANIZATION |
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A. Nonspecific manifestations of
ego weakness
1. Lack of anxiety tolerance
2. Lack of impulse control
3. Failure to sublimate |
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B. Shift toward primary process
thinking |
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C. Specific defensive operations
1. Splitting
2. Primitive idealization
3. Projection/projective identification
4. Denial
5. Omnipotence and devaluation |
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D. Pathologic internalized
object relations, identity diffusion, loosened ego boundaries |
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wish to have a need fulfilled
fulfills it. If he is hungry, he cries and is fed. |
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By the third month the infant
begins to recognize his mother is not a part of him since she
may not immediately gratify his every whim, but is still an
extension of him in that she comes soon to take care of his
needs in a symbiotic way, sharing his coo's and smiles, feeding
and changing him, and remaining largely under his control. |
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Growing up requires moving away
from this intimate dependence, separating from mother and
becoming a person in one's own right. Failure to do this,
failure of the infant to put boundaries around where he ends and
his mother and the rest of the world begin, results in failure
to establish a firm sense of self as different from the world.
Psychosis results. For example, someone hallucinating is not
able to determine that the voice he hears is really within his
head. Because of a failure of boundaries, it seems to be "out
there." |
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By the fifth month, powers of
perception are such that the infant can realize there is a world
out there, and he begins to break away from the passive position
on mother's lap, the beginning of separation and individuation
wherein the world and his mother become different from him. |
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Departing from his source of
sustenance is anxiety-provoking and can only be done if anxiety
can be reduced. The developing infant uses his memory capacity
to do this. He is now capable of creating a picture of his
mother that he can "introject into his ego," i.e. keep in mind
as a model. He can say, "This is |
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Figure 5.—MAHLER'S STAGES OF PERSONALITY DEVELOPMENT |
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Undifferentiated Symbiotic
period Differentiation Practicing Rapprochement Object
constancy
period |
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Birth 2
months 5 months 10 months 15 months 24 months |
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Psychosis Borderline Conversion Other
neuroses |
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[p.7]
my mother; this is whom I belong to." If mother is always
present to gratify his needs, he never learns to regard her as
separate from him. If mother frustrates his needs excessively by
not being available or responsive, his mind may revert to a time
when he thought she was always there. This is regressive
refusion or failure to establish the proper boundaries. Again,
psychosis results. |
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Eventually, perception and
memory tell the infant his mother doesn't always come running.
She has a nongratifying side too, a bad side. He doesn't always
feel ecstatic over her; sometimes he feels mean and nasty. To
recognize this badness in the picture of his mother and even in
his picture of himself creates more anxiety, and must be warded
off by a defense called splitting. He splits the mother picture
into two mothers, one good and one bad. They are kept apart to
protect the good one from the bad one. He does the same with his
own self picture, turns it into a good and a bad self. |
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As he begins practicing to
experience the world, he shores up the good side by another
defense. He finds other good objects out there, makes them
better than they really can be, and puts their embellished
pictures into his mind to protect him further from the bad
mother and the bad self. This defense is called primitive
idealization. |
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Yet another defense protects
him. Whereas he took the pictures of his good mother, good
objects and good self internally, he banishes the pictures of
his bad mother, bad objects, and bad self externally or projects
them onto the external world. Thus, where Aunt Edeltraud could
hold him with ease at the third month, her trying to hold him at
the seventh month causes a terrible fuss. We call this stranger
anxiety. The infant is telling himself through the fuss, "This
is not my mother, this is someone unlike her, someone bad." The
danger in projecting badness and aggression outward, attributing
it to others, is that one soon sees too many bad and aggressive
others out there to endanger one. |
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To protect one's self from them,
one must identify with them and control them. Because they are
representations of one's self, one controls one's own badness by
controlling the imagined badness of the people out there. This
is called projective identification, the attribution of a
disavowed aspect of the self to another. |
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Eventually, the infant develops
motor skills, can walk to the next room, and can be gone more
and more from mother to explore the world. The further he goes,
the greater is the separation anxiety, the thought that his good
mother will not be coming back to nurture him. To calm the
anxiety she must become involved with him and share with him the
delight of each new discovery and each new skill he acquires.
Rapprochement occurs. |
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Finally the child has developed
enough skill to be somewhat capable of satisfying his own needs.
Moreover, he learns that the mother who leaves is the same
mother who stays. Piaget's idea of the chiid's recognizing that
a chair is still a chair no matter from what angle it is viewed
applies to recognizing a mother as well. Her being gone doesn't
make her the bad internalized mother. This is merely a
frustrating aspect of her basically good self. He can rely on
this basic goodness. This is called object constancy. |
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At this point the splitting has
healed. He no longer has to keep apart the good, negative and
aggressive side of himself, but he does it in a way other than
distorting the reality of the external world and his
relationships in it. He merely does not allow its awareness to
become conscious. This we call repression. |
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If repression is incomplete,
neurosis develops. The problem with borderlines isn't partial
failure of repression such as a neurotic shows. Nor is it the
failure to differentiate self images from object images, i.e.
the loss of ego boundaries such as a psychotic shows. A
borderline person is one who fails to give up the defense
of splitting. It is an arrest of ego development at the
post-differentiation/pre-object constancy stage. |
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What are the manifestations of
this type of ego weakness (Figure 4)? First, splitting the world
and one's inner self into good and bad sides. In most of us good
and bad sides tend to neutralize our strivings into acceptable
and adaptive channels. In borderlines the split prevents
neutralization, and the aggression is unusually strong. This
explains the histrionic outbursts, the ascerbic demeanor, the
suicidal efforts, and the self-mutilation, e.g. wrist and arm
cutting which isn't suicidal but an attempt to punish the bad
side of oneself. |
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Because of splitting, abrupt
reversals of feeling occur toward others. The woman who is
enamoured with Bob this week is just as enamoured next week—with
David, while Bob is merely a fleeting memory. The wonderful
bishop who took much time to set up a budget for my patient to
get her out of debt became, in her eyes, next month the meddler
whose only concern was to extract his 10%. These abrupt
reversals of feeling also occur toward one's self. A grandiose
and wonderful self becomes a worm in the gutter, in fact, a
superlatively bad worm. The grandiosity isn't given up, the
direction just changes from grandiose self-praise to grandiose
self-reproach. |
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Second, primitive idealization,
i.e. seeing certain others as totally good and powerful, both so
they will protect one from the threatening world, and so one's
inner badness can't contaminate those others in a relationship.
Finally, association with such an ideal person provides direct
gratification of one's narcissistic needs. While seeing her
parents as hostile and the
[p.8] bishop as thwarting
her, my patient was thrilled to have become so close to the
mission president and his family. She exploited his generous
offer for help and support with unrelenting phone calls,
imposing herself on his family for holidays, and moving to his
town of residence when he was released. |
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The therapist also might be
idealized by his patient. If he questions how any person could
be so wonderful, the patient may leave rather than tolerate the
idea that the therapist is not. If one points out that a
villainous person in a patient's life can't be all bad, the
patient will ignore it if he needs the therapist enough, or will
convert the therapist into a bad person if he does not. |
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The patient does not hold
genuine regard for the idealized person. Rather he uses the
person to gratify his own needs. My patient had seen five
internists for the same medical problem, each the best doctor in
his field when first consulted, then discarded for a new best
one as his luster diminished. |
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Third, projective identification
occurs, i.e. getting someone out there to represent the
disavowed badness of one's self. Fraternizing with the enemy is
necessary to keep him from attacking one with one's own badness.
Commonly this is seen in a marriage wherein a harsh,
authoritarian male espouses a submissive, dependent female who
will express the unacceptable "weak" part of him, and then
dominates her to control the weakness. |
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A brilliant
borderline girl, to "work" her way through college,
became the mistress of a wealthy older man who fed her
narcissistic needs with expensive gifts. Her
borderline mother was appalled, yet in a classic display
of projective identification of her own erotic cravings and
narcissistic needs as belonging to her daughter, remarked to her
daughter who had just received a fur coat from her lover, "You
should have asked for mink!" |
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Fourth, denial must be invoked
to reinforce the splitting. The patient is consciously aware
that at this time his feelings, thoughts, and perceptions about
himself are at complete variance with those he may have had last
week. But the contradiction has no emotional impact on him. In
the extreme, this allows one to be a Sunday School teacher by
day and a prostitute by night. Another of my patients divorced
her husband and then went to the Young Special Interest Dances,
hopeful of finding a nice L.D.S. man who might be a future mate.
She found a nice man and told me he treated her very kindly in
bed that night. The next week she avoided him at the dance,
realizing she had slipped, met another nice man instead, and was
treated equally kindly in bed that night. |
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One patient terminated therapy
with me by declaring bankruptcy, leaving an unpaid doctor bill
of well over $1,000. When I saw her a few weeks later, she
reacted to me as an old friend and as if nothing unusual had
transpired. |
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Fifth, omnipotence and
devaluation are a common tandem. We have discussed the value of
attributing omnipotence to an idealized other, using him to
exploit and manipulate the environment and to destroy potential
enemies. There is also a self-omnipotence or aggrandizement, the
right to expect homage, to be treated as a privileged person for
whom usual rules do not apply. |
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Devaluation is the corollary. If
the object of interest can provide no further gratification or
protection, he is dropped, because no real love or attachment
existed in the first place. Devaluation prevents his becoming a
powerful persecutor. Revengeful attempts to destroy him may
appear. To the misfit
borderline teenage girl without popularity, failure to
make the pep club can only be tolerated by seeing the girls who
did as nobodies. |
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The internalized object
relations are pathological. We have said ego boundaries are
generally intact, but not totally so. They do weaken when one
uses projective identification, or when one allies with the
idealized other. This is identity diffusion and is perhaps best
seen in the "as if" person who, for lack of a good/bad
integrated self-concept, borrows whatever concept diffuses from
the outside for the moment and tries to be that kind of person.
The loosening of ego boundaries is especially true in the
transference of unstructured, insight-oriented therapy. The
capacity to see the therapist realistically fails, and the
patient may become psychotic. |
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Depression is common, but not
the depression of guilt or shame. Guilt requires experiencing of
tension between one's good and one's bad self. Acknowledging
one's aggression toward a basically good but frustrating other
brings concern for the other and shame for one's self. Splitting
eliminates the tension, hence the guilt. Many an L.D.S. bishop
has discovered the difficulty in trying to inspire to repentance
one who lacks the capacity for guilt.
Borderline depression is the depression of defeat by
external forces, impotent rage and rejection.
Borderline patients may behave in outrageous ways in
therapy to elicit rejection and usually get it. After all,
they've been at this business for years. Therapists are new at
it. |
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In relationships with others
with whom they cannot empathize and whose motives they
misevaluate, there is the "porcupine dilemma." They have a great
need to be close enough to feel the warmth but fear being
pricked by the quills. |
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Treatment can't be standardized.
Much ingenuity is required, not only to adapt treatment to the
individual patient, but to adapt it to his different ego states
at any given time. Remember, the goal is not to uncover
unconscious conflict, because that is not the problem. It is to
firm up the defective ego. This requires an active
[p.22]
therapist's being a real person, an educator, a coach, lending
the patient the benefit of one's hopefully healthy ego. He
assists the patient in seeing what role the patient does play
and could play in life, and what he can become. He helps the
patient recognize true feelings, especially the positive ones.
He enhances the patient's sense of self, giving appropriate
feedback for small accomplishments. He helps the patient improve
interpersonal skills and see the motives of people around him
realistically. He is a model of humanness, in short, the
patient's ally in the real world. |
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Deutsch, H: Some forms of
emotional disturbance and their relationship to schizophrenia.
Psychoanal Q 11:301—321, 1942 |
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Hoch P, Polatin P:
Pseudoneurotic forms of schizophrenia. Psychiat Q
23:248—276, 1949 |
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Schmideberg M: The treatment of
psychopaths and
borderline patients. Am J Psychotherapy 1:45—70,
1947 |
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Knight R:
Borderline states. Bulletin Menninger Clin
17:1—12, 1953 |
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Grinker R, Werble B, Drye R:
The
Borderline Sytndrome: A Behavioral Study of Ego
Functions. New York, Basic Books Inc, 1968 |
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Perry J, Klerman G: The
borderline patient. Arch GEn Psychiatry
35:141—150, 1978 |
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Spitzer R, Endicott J, Gibbon M:
Crossing the border into
borderline personality and
borderline schizophrenia. Arch Gen Psychiatry
36:17—24, 1979 |
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Gunderson J, Kolb J:
Discriminating features of
borderline patients. Am J Psychiatry 135:792—796,
1978 |
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American Psychiatric
Association: Diagnostic and Statistical Manual of Mental
Disorders, Third Edition. Washington, DC, American
Psychiatric Association, 1980 |
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Mahler MS, Pine F, Bergman A:
The Psychological Birth of the Human Infant. New York, Basic
Books, 1975 |
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Kernberg O:
Borderline personality organization. J Am Psychoanal
Assoc 15:641—685, 1967 |
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Pfeiffer E:
Borderline states. Dis Nerv Sys 35:212—219, 1974
[p.9] |
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Source: AMCAP
Journal, Vol.7, No. 3 (1981 Issue), pp.4-8, 22 |
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