Jerold Kreisman, Hal Straus

I hate you, just don't leave me. Borderline Personalities and How to Understand Them

Jerold J. Kreisman

Understanding the Borderline Personality

© All rights reserved including the right of reproduction in whole or in part in any form. This editon published by arrangement with Tarcher Perigee, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC.

Copyright © 2010 by Jerold J. Kreisman, MD, and Hal Straus

© Translation into Russian LLC Publishing House "Piter", 2017

© Edition in Russian, designed by Peter Publishing House LLC, 2017

© Series “Your own psychologist (hardcover)”, 2018

Still dedicated to Dudi, like all the other books

Acknowledgments

Working on this new edition required a lot of help and patience. We received tremendous support from Bruce Seymour of Goodeye Photoshare (goodeye-photoshare.com), who devoted a lot of time and effort to the technical details of preparing the manuscript. Another dear friend of ours, Eugene Horowitz, dealt with annoying computer problems. My secretaries, Jennifer Jacob and Cindy Fridley, assisted in collecting the articles and books included in this work. Lynn Klippel, an energetic librarian at the DePaul Health Center, has been mining useful links.

My partners and the staff at the St. Louis Behavior Analyst Alliance showed great patience in allowing me to complete my task. My wife Judy, my children Jenny, Adam, Brett, Alicia and babies Owen and Audrey, and the Bye Unnamed Character bravely agreed to skip a few ball games, a couple of trips to the theater and a lot of movie nights while I indulged in research and work in the sunny afternoon hours.

We would like to thank our agent, Danielle Egan-Miller of Browe & Miller Literary Associates, and John Duff and Jeanette Shaw, our publisher and editor, respectively, at Perigee/Penguin. All of them played a large role in shaping the material in this book.

Preface

When the first edition of I Hate You, Don't Leave Me was published in 1989, very little information about borderline personality disorder (BPD) was available to the general public. Research into the causes of BPD and its treatments was in its infancy. Several articles that appeared in popular magazines by that time only vaguely outlined the essence of this disorder, which was beginning to gradually penetrate the “collective consciousness of Americans.” As for patients with BPD, their families and friends, there was no information for them at all. The response to our book, both in America and abroad, where it has been translated into other languages, has been extremely positive. Apparently, I was able to fulfill my intention: to publish a work accessible to the general public, but at the same time useful for professionals thanks to good

Jerold J. Kreisman

Understanding the Borderline Personality

© All rights reserved including the right of reproduction in whole or in part in any form. This editon published by arrangement with Tarcher Perigee, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC.

Copyright © 2010 by Jerold J. Kreisman, MD, and Hal Straus

© Translation into Russian LLC Publishing House "Piter", 2017

© Edition in Russian, designed by Peter Publishing House LLC, 2017

© Series “Your own psychologist (hardcover)”, 2018

* * *

Still dedicated to Dudi, like all the other books

Acknowledgments

Working on this new edition required a lot of help and patience. Bruce Seymour from Goodeye Photoshare provided us with great support ( goodeye-photoshare.com), who devoted a lot of time and effort to the technical details of preparing the manuscript. Another dear friend of ours, Eugene Horowitz, dealt with annoying computer problems. My secretaries, Jennifer Jacob and Cindy Fridley, assisted in collecting the articles and books included in this work. Lynn Klippel, an energetic librarian at the DePaul Health Center, has been mining useful links.

My partners and the staff at the St. Louis Behavior Analyst Alliance showed great patience in allowing me to complete my task. My wife Judy, my children Jenny, Adam, Brett, Alicia and babies Owen and Audrey, and the Bye Unnamed Character bravely agreed to skip a few ball games, a couple of trips to the theater and a lot of movie nights while I indulged in research and work in the sunny afternoon hours.

We would like to thank our agent, Danielle Egan-Miller of Browe & Miller Literary Associates, and John Duff and Jeanette Shaw, our publisher and editor, respectively, at Perigee/Penguin. All of them played a large role in shaping the material in this book.

Preface

When the first edition of I Hate You, Don't Leave Me was published in 1989, very little information about borderline personality disorder (BPD) was available to the general public. Research into the causes of BPD and its treatments was in its infancy. Several articles that appeared in popular magazines by that time only vaguely outlined the essence of this disorder, which was beginning to gradually penetrate the “collective consciousness of Americans.” As for patients with BPD, their families and friends, there was no information for them at all. The response to our book, both in America and abroad, where it has been translated into other languages, has been extremely positive. Apparently, I managed to fulfill my intention: to publish a work accessible to the general public, but at the same time useful for professionals thanks to a good list of references.

Without exaggeration, we can say that colossal changes have occurred in this area over the past 20 years.

Since then, several more books have appeared on BPD, including our work Sometimes I Act Crazy (2004), which describes the disease from the perspective of those affected, their loved ones, and their doctors. Our knowledge has expanded exponentially due to a better understanding of the etiology of the disease, its biological, genetic, psychological and social consequences, and treatment approaches. So the main challenge we faced in preparing the second edition of the book was to highlight and explain the major innovations, provide useful information with references for professionals, and do all this in a way that the text could still serve as an engaging introduction to BPD. for ordinary people. To achieve this balance, some chapters needed only minor updating, while others, and especially those dealing with the possible biological and genetic roots of the syndrome, had to be virtually rewritten to incorporate the latest research findings. In addition, specific psychotherapeutic approaches and drug treatments have advanced so much that it became necessary to include new chapters in the book. This edition continues to rely on real-life examples to give the reader an understanding of what life looks like for a person with BPD and for those around them, although we have had to adjust the background of these stories somewhat to reflect the changes in American society that occurred at the turn of the century . Perhaps the most noticeable update from the first edition is the overall tone: two decades ago, the prognosis for patients was understandably rather bleak, but today (as numerous longitudinal studies allow us to judge) it looks much more positive.

However, as we review the preface to the first edition, we are saddened to acknowledge that, even with this progress, misunderstanding and especially stigmatization of borderline individuals is still common in our lives. BPD remains a disease that continues to confuse the general public and frighten many professionals. More recently, in 2009, in an article in Time it was reported that "borderline disorders are the biggest fear of psychologists" and "many psychotherapists have no idea how to treat [them]." As Marsha Linen, a leading expert on BPD, has noted, “People with BPD are the psychological equivalent of third-degree burn patients. To put it bluntly, they simply lack emotional skin. Even the slightest touch or movement can cause them unimaginable suffering." 1
Here and further notes for the chapters can be downloaded from the link: https://goo.gl/v1jExS.

2
John Cloud, “Minds on the Edge,” Time(January 19, 2009): 42–46.

However, the development of specific therapies and medications for the disorder (see Chapters 8 and 9) has alleviated some of the burden for patients, and perhaps more importantly, public awareness of BPD has increased markedly since 1989. . As you will see in the Helpful Resources section at the end of this publication, the number of books, websites, and support groups has increased significantly. Perhaps the most obvious manifestation of public acceptance came in 2008, when Congress designated May as “Borderline Personality Disorder Awareness Month.”

However, we still face a number of major challenges, especially financial ones. Reimbursement for cognitive health services remains obscenely and disproportionately low. For an hour of psychotherapy, most insurance companies (as well as the federal Medicare program) pay less than 8% of the amount provided for minor outpatient surgery, such as a fifteen-minute cataract operation. Research on BPD is also clearly under-conducted. The lifetime disease risk in the population for BPD is twice as high as for schizophrenia and bipolar disorder combined, yet the National Institute of Mental Health (NIMH) allocates less than 2% of the grants for BPD research to these less common illnesses 3
John G. Gunderson, “Borderline Personality Disorder: Ontogeny of a Diagnosis,” 166 (2009): 530–539.

As our country strives to control health care costs, we must understand that investments in research will ultimately contribute to improving the nation's health and thus reduce health care costs in the long term. But this will require re-prioritizing the allocation of limited resources and recognizing that subsidy rationing can affect not only the quality of care, but also progress in treatment.

Among professionals and other readers, many have spoken favorably of the original publication as a "classic" in the field. Two decades later, we were only too happy to review our work and add to it the voluminous information accumulated during this period. I hope, updated and refreshed, our work will help us play at least a small role in eliminating misunderstandings and ending the stigmatization of those with BPD, and maintain the honor of being widely considered the primary authority on this issue.

Dr. Jerold J. Kreisman

Note to reader

Most books on health-related topics are written using style guidelines (see, for example, the American Psychological Association's Publication Manual) designed to minimize the stigma of a given disease and to formulate politically correct gender definitions. In particular, defining an individual by his illness is discouraged (e.g., “a schizophrenic usually has...”); it must be about a person who exhibits symptoms of the disease (for example, “a patient diagnosed with schizophrenia usually has...”). It is also recommended to avoid gendered pronouns; instead, impersonal constructions or combinations of “he/she, his/her” are used.

While these recommendations are laudable in many respects, they make for difficult reading. While we strongly disapprove of the disrespect and dehumanization that can occur in defining people by their diagnosis (“Look at that ulcer in the next room!”), we have decided to occasionally use such descriptions for clarity and accessibility. Thus, we use the term “borderline personality” as shorthand for a more precise definition: “a person exhibiting symptoms consistent with the diagnosis of borderline personality disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, 4th edition, revised text ( DSM-IV-TR)". For the same reason, we use different personal pronouns throughout the book, preferring not to burden the reader with he/she, his/her constructions. We believe that readers will forgive us for taking this liberty with the text for the sake of simplifying it.

Chapter 1: The World of the Borderline Personality

Everything looked and sounded unreal. Nothing was what it really was. That's what I wanted - to be alone with myself in another world, where the truth is deceiving, and life can hide from itself.

Eugene O'Neill. Long day goes into night

Dr. White thought it would be quite simple. In the five years he saw Jennifer, she rarely had any health problems. He initially considered her stomach complaints to be a consequence of gastritis and treated her with antacids. But when the abdominal pain worsened despite treatment, and routine tests showed everything was normal, he sent Jennifer to the hospital.

After a thorough medical examination, Dr. White asked Jennifer if she was experiencing stress at work and at home. She immediately admitted that her job as an HR manager in a large company is quite difficult, but added that “many people have nervous work.” Jennifer also said that her family life has recently become more stressful: she tried to help her husband with his legal affairs, while fulfilling the duties of a mother every day. However, she doubted that these factors could have anything to do with her pain.

When Dr. White recommended that Jennifer seek counseling, she was initially reluctant. Only after the discomfort developed into acute attacks of pain did she reluctantly agree to see a psychiatrist, Dr. Gray.

A few days later they met. Jennifer was a pretty blonde and looked younger than her 28 years. She was lying in bed in a hospital room that had turned from a soulless room into a cozy nest. There was a stuffed animal sitting on the bed next to the patient, and another one was lying on the nightstand not far from photographs of her husband and child. Get-well cards were neatly placed on the windowsill in a line framed by flower arrangements.

At first, Jennifer behaved completely normally, answering all of Dr. Gray's questions with the utmost seriousness. Then she joked that her new job had “turned her into a shrink.” And the more she spoke, the sadder she became. Her voice became less powerful and took on a childish note.

She told the doctor that the promotion came with new responsibilities and demands, making her feel insecure. Her five-year-old son started going to school, and this separation from each other was not easy for them. She increasingly clashed with Allan, her husband. She also mentioned sudden mood swings and sleep problems. Her appetite gradually worsened and she lost weight. Concentration, energy and sex drive all waned.

Dr. Gray recommended she try antidepressants, which improved her stomach pain and seemed to normalize her sleep patterns. After a few days, Jennifer was ready to be discharged and agreed to continue outpatient treatment.

Over the following weeks, Jennifer talked more and more about her upbringing. She was the daughter of a prominent businessman and his socialite wife, and grew up in a small town. Her father, an elder at the local church, demanded perfection in everything from his daughter and her two older brothers, constantly reminding the children that the community was monitoring their behavior. Jennifer's grades, her actions, even her thoughts were never good enough for him. She was afraid of her father and yet she constantly - and unsuccessfully - tried to win his approval. Her mother remained passive and distant. Her parents often judged her friends, often calling them bad company. As a result, she had few friends and even fewer romantic relationships.

Jennifer described her emotions as being on a roller coaster, which only got worse as she entered college. There she first began to drink, sometimes even excessively. All of a sudden she could feel depressed and lonely, and then suddenly fly into seventh heaven with happiness and love. Sometimes she would lash out at her friends in fits of rage - as a child she somehow managed to suppress these fits of anger.

Around the same time, she began to appreciate male attention, which she had previously always avoided. And although she loved being desired, she always felt that she was somehow “fooling” or deceiving men. When she started dating a man, she often sabotaged the relationship by starting a conflict.

She met Allan just as he was finishing his law degree. He pursued her tirelessly and refused to back down when she tried to back down. He liked to choose clothes for her and advise her on how to walk, how to talk and how to eat properly. He insisted that she join him in going to the gym where he often worked out.

As Jennifer herself explained, Allan gave her an individuality. He advised her how to communicate with his partners and clients, told her when to be aggressive and when to be modest. She formed within herself an entire “troupe of actors”—characters or role players whom she could call on stage at any moment.

They married at Allan's insistence before the end of her first year. She quit her studies and began working as a secretary, but her employer recognized her great intelligence and transferred her to a more responsible position.

Nevertheless, the situation in the family began to heat up. Allan's career and interest in exercise forced him to spend more and more time away from home, and Jennifer was extremely irritated by this. Sometimes she would pick fights just to keep him at home a little longer. Often she even provoked him to hit her. After that, she invited him to make love.

Jennifer still had few friends. She despised women because they gossiped and were generally boring. She hoped that Scott's birth two years after the wedding would give her the comfort she needed. She thought that her son would always love her and never leave her. But the child required a lot of effort, and after some time Jennifer decided to return to work.

Despite regular praise and a successful career, Jennifer still felt insecure and felt like she was imitating life. She entered into an intimate relationship with a colleague who was almost 40 years older than her.

“I’m usually fine,” she told Dr. Gray. “But there is another side of me that sometimes takes over and begins to control me. I'm a good mother. But my other side makes me a whore; she makes me act like I'm crazy!

Jennifer continued to make fun of herself, especially when she was alone; in moments of solitude, she felt abandoned, attributing this to the fact that she was unworthy of anyone else. Anxiety often threatened to completely overwhelm her if she did not find some way out for it. Sometimes she indulged in gluttony, eating an entire bowl of cookie dough at a time. She would spend many hours looking at photographs of her son and husband, trying to “bring them to life in her mind.”

Jennifer's appearance during her psychotherapy sessions could be very different. Arriving straight after work, she was dressed in a business suit and just radiated maturity and prudence. But on weekends she showed up in short trousers and knee socks, with her hair braided; at these meetings she acted like a little girl with a high-pitched voice and a rather limited vocabulary.

Sometimes she transformed right before Dr. Gray's eyes. She could be insightful and intelligent, collaborating with the doctor to better understand herself, and then suddenly become childish, flirtatious and seductive, declaring herself unable to function in the adult world. She could be charming and ingratiating, or manipulative and hostile. She might storm out of the office in a rage during one session, vowing never to return, and the next time she would cower in fear that Dr. Gray would refuse to see her again.

Jennifer felt like a child wearing the armor of an adult. She was confused by the respect with which other adults treated her; she expected them to see what was behind her mask at any moment, putting her in the position of a naked queen. She needed someone to love and who would protect her from the world. She desperately wanted closeness, but as soon as someone got too close, she ran away.

Jennifer suffers from borderline personality disorder (BPD). And she is not alone in this. Recent research suggests that at least 18 million Americans (almost 6% of the country's population) exhibit primary symptoms of BPD, but many argue that this figure is a significant underestimate 4
Bridget F. Grant, S. Patricia Chou, Rise B. Goldstein, et al., “Prevalence Correlates, Disability, and Comorbidity of DSM-IV Borderline Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions,” Journal of Clinical Psychiatry 69 (2008): 533–544.

About 10% of outpatient and 20% of inpatient psychiatric patients are diagnosed with BPD, as are 15–25% everyone patients seeking psychiatric help. This disease is one of the most common types of personality disorders. 5
John G. Gunderson Borderline Personality Disorder(Washington, DC: American Psychiatric Publishing, 1984).

6
Klaus Lieb, Mary C. Zanarini, Christian Schmahl, et al., “Borderline Personality Disorder,” Lancet 364 (2004): 453–461.

7
Mark Zimmerman, Louis Rothschild, and Iwona Chelminski, “The Prevalence of DSM-IV Personality Disorders in Psychiatric Outpatients,” American Journal of Psychiatry 162 (2005): 1911–1918.

However, despite its prevalence, BPD remains a relatively unknown disease to the general public. Ask people on the street about anxiety neurosis, depression or alcoholism, and they will most likely be able to describe these diseases in general terms, if not exactly in detail. Ask them about borderline personality disorder and you'll probably get a blank stare. However, if you ask an experienced mental health professional about this disorder, you will see a completely different reaction. He will take a deep breath and exclaim that of all psychiatric patients, borderlines are the most difficult, the most feared and avoided - far more often than schizophrenics, alcoholics or any other patients. For more than a decade, BPD lurked in the margins, a kind of “third world” in the universe of mental illness—vague, vast, and vaguely threatening.

BPD has rarely been recognized, in part because the diagnosis is relatively new. For many years, the term “borderline” was used as an umbrella term for a category of patients who did not fit conventional diagnoses. People described as “borderline” seemed more ill than neurotics (those who experience high levels of anxiety as a consequence of emotional conflict) but less ill than psychotics (who are disconnected from reality and therefore unable to function normally).

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

Although the term borderline personality was first coined in the 1930s, the disorder itself was not clearly defined until the 1970s. For many years, psychiatrists could not seem to agree on whether to identify this syndrome as a separate disease, let alone specific symptoms to diagnose it. But as more people began to seek help with a specific and specific set of life problems, the parameters of the disorder began to gradually crystallize. In 1980, the diagnosis of borderline personality disorder was first defined in the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the diagnostic "bible" of psychiatrists. Since then, the manual has been revised several times, and the latest edition at the time of writing is DSM-IV-TR, published in 2000 8
The current DSM-V is in force, introduced in 2013, replacing the previous manual. – Note lane.

Although different schools of psychiatry still debate the exact nature, causes, and treatment of BPD, the disorder is officially recognized as a major mental health problem in America today. Indeed, patients with BPD consume a much higher percentage of mental health services than patients with any other diagnosis. 9
Donna S. Bender, Andrew E. Skodol, Maria E. Pagano, et al., “Prospective Assessment of Treatment Use by Patients with Personality Disorders,” Psychiatric Services 57 (2006): 254–257.

10
Marvin Swartz, Dan Blazer, Linda George, et al., “Estimating the Prevalence of Borderline Personality Disorder in the Community,” Journal of Personality Disorders 4 (1990): 257–272.

In addition, research confirms that about 90% of patients diagnosed with BPD also have at least one other psychiatric diagnosis. 11
James J. Hudziak, Todd J. Boffeli, Jerold J. Kreisman, et al., “Clinical Study of the Relation of Borderline Peronality Disorder to Briquet’s Syndrome (Hysteria), Somatization Disorder, Antisocial Personality Disorder, and Substance Abuse Disorders,” American Journal of Psychiatry 153 (1996): 1598–1606.

12
Mary C. Zanarini, Frances R. Frankenburg, John Hennen, et al., “Axis I Comorbidity in Patients with Borderline Personality Disorder: 6-Year Follow-Up and Prediction of Time to Remission,” American Journal of Psychiatry 161 (2004): 2108–2114.

Jerold J. Kreisman

Understanding the Borderline Personality

© All rights reserved including the right of reproduction in whole or in part in any form. This editon published by arrangement with Tarcher Perigee, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC.

Copyright © 2010 by Jerold J. Kreisman, MD, and Hal Straus

© Translation into Russian LLC Publishing House "Piter", 2017

© Edition in Russian, designed by Peter Publishing House LLC, 2017

© Series “Your own psychologist (hardcover)”, 2018

Still dedicated to Dudi, like all the other books

Working on this new edition required a lot of help and patience. Bruce Seymour from Goodeye Photoshare provided us with great support ( goodeye-photoshare.com), who devoted a lot of time and effort to the technical details of preparing the manuscript. Another dear friend of ours, Eugene Horowitz, dealt with annoying computer problems. My secretaries, Jennifer Jacob and Cindy Fridley, assisted in collecting the articles and books included in this work. Lynn Klippel, an energetic librarian at the DePaul Health Center, has been mining useful links.

My partners and the staff at the St. Louis Behavior Analyst Alliance showed great patience in allowing me to complete my task. My wife Judy, my children Jenny, Adam, Brett, Alicia and babies Owen and Audrey, and the Bye Unnamed Character bravely agreed to skip a few ball games, a couple of trips to the theater and a lot of movie nights while I indulged in research and work in the sunny afternoon hours.

We would like to thank our agent, Danielle Egan-Miller of Browe & Miller Literary Associates, and John Duff and Jeanette Shaw, our publisher and editor, respectively, at Perigee/Penguin. All of them played a large role in shaping the material in this book.

When the first edition of I Hate You, Don't Leave Me was published in 1989, very little information about borderline personality disorder (BPD) was available to the general public. Research into the causes of BPD and its treatments was in its infancy. Several articles that appeared in popular magazines by that time only vaguely outlined the essence of this disorder, which was beginning to gradually penetrate the “collective consciousness of Americans.” As for patients with BPD, their families and friends, there was no information for them at all. The response to our book, both in America and abroad, where it has been translated into other languages, has been extremely positive. Apparently, I managed to fulfill my intention: to publish a work accessible to the general public, but at the same time useful for professionals thanks to a good list of references.

Without exaggeration, we can say that colossal changes have occurred in this area over the past 20 years. Since then, several more books have appeared on BPD, including our work Sometimes I Act Crazy (2004), which describes the disease from the perspective of those affected, their loved ones, and their doctors. Our knowledge has expanded exponentially due to a better understanding of the etiology of the disease, its biological, genetic, psychological and social consequences, and treatment approaches. So the main challenge we faced in preparing the second edition of the book was to highlight and explain the major innovations, provide useful information with references for professionals, and do all this in a way that the text could still serve as an engaging introduction to BPD. for ordinary people. To achieve this balance, some chapters needed only minor updating, while others, and especially those dealing with the possible biological and genetic roots of the syndrome, had to be virtually rewritten to incorporate the latest research findings. In addition, specific psychotherapeutic approaches and drug treatments have advanced so much that it became necessary to include new chapters in the book. This edition continues to rely on real-life examples to give the reader an understanding of what life looks like for a person with BPD and for those around them, although we have had to adjust the background of these stories somewhat to reflect the changes in American society that occurred at the turn of the century . Perhaps the most noticeable update from the first edition is the overall tone: two decades ago, the prognosis for patients was understandably rather bleak, but today (as numerous longitudinal studies allow us to judge) it looks much more positive.

However, as we review the preface to the first edition, we are saddened to acknowledge that, even with this progress, misunderstanding and especially stigmatization of borderline individuals is still common in our lives. BPD remains a disease that continues to confuse the general public and frighten many professionals. More recently, in 2009, in an article in Time it was reported that "borderline disorders are the biggest fear of psychologists" and "many psychotherapists have no idea how to treat [them]." As Marsha Linen, a leading expert on BPD, has noted, “People with BPD are the psychological equivalent of third-degree burn patients. To put it bluntly, they simply lack emotional skin. Even the slightest touch or movement can cause them unimaginable suffering." However, the development of specific therapies and medications for the disorder (see Chapters 8 and 9) has alleviated some of the burden for patients, and perhaps more importantly, public awareness of BPD has increased markedly since 1989. . As you will see in the Helpful Resources section at the end of this publication, the number of books, websites, and support groups has increased significantly. Perhaps the most obvious manifestation of public acceptance came in 2008, when Congress designated May as “Borderline Personality Disorder Awareness Month.”

However, we still face a number of major challenges, especially financial ones. Reimbursement for cognitive health services remains obscenely and disproportionately low. For an hour of psychotherapy, most insurance companies (as well as the federal Medicare program) pay less than 8% of the amount provided for minor outpatient surgery, such as a fifteen-minute cataract operation. Research on BPD is also clearly under-conducted. The lifetime disease risk in the general population for BPD is twice that of schizophrenia and bipolar disorder combined, yet the National Institute of Mental Health (NIMH) allocates less than 2% of the grants for BPD research to these less common illnesses. As our country strives to control health care costs, we must understand that investments in research will ultimately contribute to improving the nation's health and thus reduce health care costs in the long term. But this will require re-prioritizing the allocation of limited resources and recognizing that subsidy rationing can affect not only the quality of care, but also progress in treatment.

Among professionals and other readers, many have spoken favorably of the original publication as a "classic" in the field. Two decades later, we were only too happy to review our work and add to it the voluminous information accumulated during this period. I hope, updated and refreshed, our work will help us play at least a small role in eliminating misunderstandings and ending the stigmatization of those with BPD, and maintain the honor of being widely considered the primary authority on this issue.

Borderline personality disorder and suicide

No less than 70% of patients with BPD attempt suicide, and the proportion of successful attempts approaches 10% - this is almost a thousand times higher than the same figure for the general population. In the high-risk group of adolescents and young adults (ages 15–29 years), BPD was diagnosed in a third of suicide cases. Hopelessness, impulsive aggression, major depression, drug use, and childhood abuse are increased risk factors. Although anxiety is often associated with suicide in other illnesses, BPD patients with significant levels of anxiety are, in contrast, less likely to commit suicide 19–21.

Clinical definition of borderline personality disorder

The current official definition of borderline pathology is contained in the diagnostic criteria for borderline personality disorder in the DSM-IV-TR. This definition emphasizes demonstrable, observable behavior.

A diagnosis of BPD can be confirmed when at least five of the following nine criteria are present.

“Others influence me, therefore I exist.”

Criterion 1. Persistent attempts to avoid real or imagined loneliness

Just as an infant does not see the difference between the temporary absence of the mother and her “disappearance,” so the borderline personality often perceives temporary loneliness as eternal isolation. As a result, she becomes depressed due to real or imagined abandonment by people important to her, and then furious at the whole world (or at whomever comes to hand).

The fear of loneliness in BPD patients can even be measured by brain function. Positron emission tomography used in one study showed that women with BPD had changes in blood flow to specific lobes of the brain when they recalled memories of loneliness. Borderlines, especially if they are lonely, may lose their sense of existence or their own reality. They are not close to the Cartesian principle “I think, therefore I am”; they live in accordance with a philosophy that can be formulated as “others influence me, therefore I exist.”

Theologian Paul Tillich wrote that “loneliness can only be overcome by those who are able to endure solitude.” Because the borderline finds solitude so difficult to tolerate, he or she is trapped in an endless metaphysical loneliness, the only relief from which comes in the form of the physical presence of others. That's why he so often runs headlong into dating bars or other crowded places, despite the fact that the result is often disappointment or even cruelty.

In the film Marilyn: The Untold Story, Norman Rosten recalled how Marilyn Monroe hated being alone. If there were no people around her at all times, she would fall into an “endless and frightening” void.

For most of us, solitude is something desired, valuable, a rare opportunity to engage with our memories and things that are important to us, a chance to connect with ourselves, to rediscover who we are: “The walls of an empty room are mirrors that endlessly reflect a person as he imagines himself,” wrote John Updike in “The Centaur.”

However, a person suffering from BPD with a barely discernible sense of self looks only at empty reflections. The solitude represents the panic he felt as a child when faced with the prospect of being abandoned by his parents: who will take care of me then? The pain of loneliness can only be eased by the salvation of an imaginary lover, which is often reflected in the lyrics of a myriad of love songs.

The Relentless Search for Mr./Ms. Just What You Need

Criterion 2. Unstable and tense interpersonal relationships with marked changes in attitudes towards others (from idealization to devaluation or from acute dependence to isolation and avoidance), as well as obvious patterns of manipulating others

The borderline's unstable relationships with others are directly related to his intolerance of isolation and fear of intimacy. Typically, the borderline personality is dependent on, attached to, and idealizes their partner, spouse, or friends until they push her away with some act of indifference or rejection, at which point she is thrown to the other extreme of devaluing them, resisting intimacy, and outright avoiding them. . A constant tug-of-war begins between the need for community and care, on the one hand, and the fear of engulfment, on the other. For the borderline personality, such absorption means the destruction of identity, loss of autonomy and sense of self-existence. The patient oscillates between the desire for close connection, which would save him from emptiness and boredom, and the fear of intimacy, which, as it seems to him, can rob him of self-confidence and independence.

In relationships, these feelings are dramatically transformed into tense, changeable and manipulative connections. A person with BPD often makes unrealistic demands on others and appears spoiled to an outside observer. Manipulativeness is expressed in complaints about physical condition and hypochondria, manifestations of weakness and helplessness, provocations and masochistic behavior. Suicide threats or suicidal gestures are often used to attract attention and help. The borderline may resort to seduction as a manipulation strategy, even when it comes to someone with whom it is inappropriate to behave in such a way and who is inaccessible to her, such as a doctor or priest.

Although BPD people are very sensitive to others, they lack true empathy. Meeting an acquaintance, such as a teacher, co-worker, or doctor, outside of their usual “situation” can be disconcerting for the borderline because it is difficult for them to imagine them having a life separate from their roles. Moreover, a person with BPD may not understand or be extremely jealous of the personal lives of their doctor or even other patients they know.

Patients with BPD lack “object constancy,” the ability to view others as complex human beings who can also form consistent relationships. They perceive others based on the impressions of the last meeting, rather than on the basis of a long series of interactions. Thus, borderline individuals do not form a stable, predictable idea of ​​​​the other person - they react to him as a stranger at every meeting, as if suffering from narrow-minded amnesia.

Because of the patient's inability to see the big picture, learn from mistakes, and observe patterns in his behavior, he often re-engages in destructive relationships. Women with BPD, for example, often return to abusive ex-husbands who continue to abuse them; men often end up with similar partners who are not suitable for them, repeating past sadomasochistic attachments. Because borderlines' addiction is often hidden under the guise of passion, they continue in destructive relationships "because I love him/her." Later, when the relationship breaks down, one partner often blames the pathology of the other. So in the psychoanalyst’s office you can often hear: “My first wife was borderline!”

The never-ending “quest” for the borderline personality is to find the ideal caregiver who will give everything and will always be there. The search often leads to partners with complementary pathologies: both lack the ability to understand their mutual destructiveness. For example, Michelle desperately needs the protection and comfort of a man. Mark displays bravura self-confidence; Even though she masks his inner weakness, this is enough for Michelle. Just as Michelle needs the noble knight Mark, so Mark needs Michelle, who will be helpless and dependent on his generosity. After some time, both will not be able to live up to the stereotypes assigned to them. Mark is unable to lick his narcissistic wounds from problems and failures and begins to drown his frustrations in alcohol, while beating Michelle. Michel bristles under his tyrannical yoke, but is frightened when he sees his weakness. Dissatisfaction leads to new provocations and conflicts.

A self-loathing person with BPD constantly distrusts others' expressions of concern for them. Like Groucho Marx, he will never join a club that is willing to include him as a member. For example, Sam, a 21-year-old college student, complained to a psychologist primarily about “needing a girlfriend.” As an attractive young man with serious interpersonal problems, he tended to be attracted to women who seemed unattainable to him. However, every time his attempt to make an acquaintance was successful, he immediately devalued the woman who accepted her, and she ceased to be desirable to him.

All of these qualities prevent the borderline personality from achieving real intimacy. As Carrie said, “Several men have wanted to marry me, but I have a big problem with intimacy and physical touch. I can't stand it." A person with BPD seems to lack the independence to be able to need someone without going to extremes. True intimacy is sacrificed to demanding dependence and the desperate need to connect with another person to complete one's own identity, a kind of spiritual Siamese twin. “You complete me” - this famous phrase from “Jerry Maguire” turns into an unattainable goal.

Who am I?

Criterion 3. Noticeable and persistent identity disorder, expressed in instability of self-perception and self-image

Borderline individuals lack a stable core of identity, just as they lack a stable core for conceptualizing others. The borderline personality perceives his intelligence, attractiveness, and sensitivity not as permanent traits, but rather as comparative qualities that are constantly re-evaluated and measured against similar qualities of others. For example, a woman with BPD may consider herself intelligent based on the results of an IQ test she just took. But later that day she will make a “stupid mistake” and again decide that she is “stupid.” Or she seems attractive to herself until she sees a woman who is more attractive, from her point of view, and again considers herself “ugly.” Of course, a person with BPD may envy Popeye the Sailor's ability to accept himself, saying, “I am who I am.” As in close relationships, borderline individuals suffer from a kind of amnesia - only about themselves. The past is obscured; a person becomes like a demanding boss who constantly asks himself and others: “Yes, so what? What have you done for me lately?

For a patient with BPD, identity is like a curve on a graph. Who he is and what he does today determines his worth; what came before is not taken into account. He doesn't allow himself to rest on his laurels. Like Sisyphus, he is doomed to roll up a huge stone over and over again, proving his worth again and again. The borderline person can achieve high self-esteem only by impressing others, so the desire to please everyone becomes critical to her ability to love herself.

In his book Marilyn, Norman Mailer describes how Marilyn Monroe's pursuit of identity became her driving force, consuming every aspect of her life:

What an obsession this identity is! We are looking for it, because, being within the framework of our own “I”, with some corner of our being we feel that we are sincere when we say that we really exist, and this local feeling of self-satisfaction hides an existential secret, no less important for psychology rather than cogito ergo sum [I think, therefore I am], in other words, the emotional state caused by such a sense of self is somehow so preferable to the feeling of inner emptiness that for its bearers - such as Marilyn - it can become a more powerful motivating stimulus, than the sexual instinct, the desire for high social status or wealth. Some would rather sacrifice love or their own safety than risk losing the comfort of having an identity.

Marilyn later found support in acting, and especially in the so-called “Method”:

According to the Method, the actors had to win; This technique is designed by analogy with psychoanalysis to give vent to an avalanche of emotions and thus allow the actor to look into the depths of himself, in order to then master himself so that his role can master him. Magic metamorphosis. Here we can mention Marlon Brando in A Streetcar Named Desire. Surrendering to the power of a role is like satori (or intuitive enlightenment) for an actor, because his identity can seem complete to him only while he lives in the role.

The borderline person's struggle for a stable identity is associated with the dominant feeling that he is not “real”, that he is just “pretending.” Most of us experience something similar at some point in our lives. For example, when we start a new job, we try to exude a false confidence and learning. With experience, this confidence gradually becomes more and more natural, because now we have it all figured out and there is no point in pretending anymore. As Kurt Vonnegut wrote, “We are who we pretend to be.” Or, as some say, “fake it until you make it.”

A person with BPD never achieves this level of confidence. He continues to feel like he is faking it, and he is constantly afraid that he is about to be “found out.” This is especially true in cases where he achieves any success - he feels out of place, his luck - undeserved.

This chronic feeling of pretense and simulation probably stems from childhood. As we will discuss in Chapter 3, the future patient with BPD often grows up with a sense of inauthenticity due to various external circumstances: physical or sexual abuse, the need to take on the role of an adult, for example, caring for an ill parent. The other extreme is when a person is prevented in every possible way from growing up and separating from his parents, and he finds himself trapped in a dependent childhood role for many years. In all of these situations, the borderline personality never achieves a full sense of self, but continues to “pretend” to play the role assigned to it by someone else. If a person suffering from BPD fails to cope with a role, he is afraid of punishment; if he succeeds in the game, he is sure that the deception will soon be revealed and humiliation will follow.

The desire for illusory perfection is often an integral part of the borderline behavior pattern. For example, an anorexic with BPD tries to maintain a low weight and is horrified by even gaining half a kilo, while completely unaware that such expectations for themselves are unrealistic. Perceiving their condition as something static rather than a dynamic process of change, borderline individuals may view any deviation from this rigid picture of self-perception as its complete destruction.

There are also opposite situations when borderline individuals seek comfort in the opposite way, often changing jobs, careers, goals, friends, and sometimes even gender. By seeking novelty and making drastic changes in their lifestyle, they hope to achieve spiritual satisfaction. Some cases of the so-called midlife crisis or male menopause represent an attempt to ward off the fear of death or cope with disappointment with one's life choices. A teenager with BPD may constantly change their circle of friends, rushing from “jocks” to “goofballs”, and from them to “smart guys” or “geeks” in the hope of feeling a sense of belonging to something and being accepted into the group. Even sexual identity can sometimes become a source of confusion for borderline individuals. Some researchers have noted an increased proportion of homosexuals, bisexuals, and those prone to sexual perversion among patients with BPD.

The borderline personality finds particularly attractive cult groups that promise unconditional acceptance, structured social frameworks, and limited and clearly defined boundaries of identity. When an individual's identity and value system merges with the host group, its leader acquires extraordinary power, to the point that he can persuade followers to copy his actions, even fatal ones, as demonstrated by the Jonestown mass suicide in 1978, a fatal encounter with members of the group " Branch of David" in 1993 and mass suicides of members of the "Gates of Heaven" sect in 1997.

After dropping out of college, Aaron tried to ease his sense of meaninglessness by joining the Moonies. Two years later, he left the sect, but after another two years of aimlessly wandering around different cities and changing different jobs, he returned. Ten months later, he left the group again, but this time, unable to find clear goals and understand who he was and what he wanted, Aaron attempted suicide.

The phenomenon of "group suicide", especially among adolescents, may reflect weakness in identity formation. The number of suicides across the country jumps sharply after the suicide of a famous figure, someone like Marilyn Monroe or Kurt Cobain. Similar dynamics can be observed among adolescents with an unstable identity construction: they are susceptible to the suicidal tendencies of the leader of their peer group or other suicidal groups of adolescents in the same region.

Impulsive character

Criterion 4: Impulsivity in at least two potentially destructive behaviors, such as alcohol and drug abuse, sexual promiscuity, gambling, reckless driving, shoplifting, excessive spending, overeating

The actions of a person with BPD can be sudden and internally contradictory because they are based on strong momentary feelings and perceptions that are separate, disconnected pictures from life experiences. The present exists for him as if in isolation from the lessons of past experience and expectations from the future. Because the concepts of historical cycles, consistency and predictability are inaccessible to him, he repeats the same mistakes over and over again. Released in 2001, the film Memento metaphorically describes what the borderline personality regularly faces. Suffering from short-term memory loss, insurance investigator Leonard Shelby is forced to cover his room with Polaroids, sticky notes, and even tattoos to remind himself of what happened just hours or minutes ago. (In one chase scene, when he tries to avenge his wife's murder, he can't even remember whether he's running away or catching up with an enemy!) The film rather tragically illustrates the loneliness of a man who constantly feels like he's just woken up. Borderlines' limited patience and need for immediate gratification may be associated with behaviors that define other criteria for BPD: impulsive conflict or rage may stem from frustration with overly turbulent relationships (Criterion 2); sudden changes in mood (criterion 6) can lead to impulsive outbursts; inappropriate outbursts of rage (criterion 8) may result from an inability to control impulses; self-destruction or self-harm (criterion 5) may result from depression and frustration. Often, impulsive behavior, such as drug and alcohol abuse, serves as a defense mechanism against loneliness and feelings of abandonment.

Joyce went through a divorce by the age of 31 and increasingly turned to alcohol for solace after separating from her husband and his remarriage. Despite her attractiveness and talents, she neglected her work and spent more and more time in bars. As she later put it, “I made a career out of avoidance.” When the pain of loneliness and abandonment became unbearable, she turned to alcohol as an anesthetic. Sometimes she met men and went with them to her home. Typically, after such alcoholic and sexual revelry, she was consumed by a feeling of guilt and the feeling that she deserved to be abandoned by her husband. Then this cycle began again, as she required more and more severe punishment for her worthlessness. Thus, self-destruction became both a way for her to avoid pain and inflict it on herself as an atonement for her sins.

Self-destruction

Criterion 5. Recurrent threats of suicide, suicidal gestures or behavior, intentional self-harm

Threats of suicide and suicidal gestures are prominent features of BPD and simultaneously reflect borderline patients' tendency toward overwhelming depression, hopelessness, and the ability to manipulate others.

Episodes of self-harm among borderline individuals are quite common, occurring in 75% of cases, and the vast majority of these patients make at least one suicide attempt. Often, regular threats or hesitant suicide attempts are not explained by a desire to die, but rather by an attempt to talk about their pain and ask for help. Unfortunately, when repeated over and over again, these suicidal gestures often lead to the opposite: those around them become fed up with the behavior and stop responding to it, which can lead to progressively more serious attempts in subsequent attempts. Suicidal behavior is one of the most difficult symptoms of BPD for families and doctors of patients: attempts to cope with it can lead to endless and unproductive confrontation; ignoring it can lead to death (see chapters 6-8). Although the defining criteria of BPD become less pronounced over time, the risk of suicide persists throughout life. Borderlines who experienced childhood sexual abuse are ten times more likely to attempt suicide.

Another symptom of BPD is self-harm, unless it is clearly associated with psychosis. These behaviors are more closely associated with BPD than any other mental illness and can manifest as damage to the genitals, limbs, or torso. For such borderline patients, the body becomes a kind of map on which a lifelong route of scars is marked. The most common uses are razors, scissors, fingernails and lit cigarettes; In addition, you can harm yourself by excessive consumption of alcohol, drugs or even food.

Self-harm often begins as an impulsive act of self-punishment, but over time becomes an elaborate ritual. In such cases, the borderline may discreetly scar parts of the body hidden under clothing, which illustrates his extreme ambivalence: he feels drawn to visual self-flagellation, but still hides evidence of his distress. Although many people get tattoos for purely decorative purposes, the growing popularity of tattoos and piercings throughout society in the last couple of decades may be less a fashion trend and more a reflection of growing fringe trends in society (see Chapter 4).

Jennifer (see Chapter 1) satisfied her need for pain by scratching her wrists, stomach, and waist, leaving deep fingernail marks that could easily be covered up.

Sometimes the desire to punish oneself takes less obvious forms. A borderline personality can often become a victim of ongoing “quasi-incidents” and provoke fights. In such situations, she feels less personal responsibility: cruelty is provided by circumstances or other people.

For example, when Harry broke up with his girlfriend, he blamed his parents for it. He felt they were not supportive enough and too unfriendly, and when his affair ended six years later he found himself completely abandoned. At 28, he continued to live in the apartment his parents paid for and worked occasionally in his father's office. He had previously attempted suicide, but decided that he did not want to “do such a favor” for his parents. Instead, he began to behave increasingly dangerously. He was involved in car accidents several times, including while drunk, and continued to drive despite having his license revoked. He was a regular at bars, where he sometimes got into fights with much stronger opponents. Harry recognized the destructiveness of his behavior and sometimes wished that “in one of these scrapes I would just die.”

This dramatic self-destructive behavior and threats can be explained in several ways. Self-inflicted pain reflects the borderline personality's need for feelings, his desire to break out of the capsule of numbness. Patients with BPD form a kind of insulating bubble around themselves, which not only protects them from emotional pain, but also serves as a barrier between them and the sense of reality of what is happening. In this situation, pain becomes an important connection with existence for them. However, self-inflicted pain is often not strong enough to overcome this barrier (although the very sight of blood and scars may attract them), in which case frustration may drive patients to inflict more pain on themselves.

Physical pain can also be a way to distract from other forms of suffering. One patient, in moments of loneliness and fear, cut various parts of her body to “take her mind off” her worries. Another brought herself to a painful nervous migraine. So one of the most common reasons that causes people with BPD to self-harm is the desire to relieve internal tension.

The behavior described can also serve as a method of atonement for sins. One man, overcome with guilt after the breakup of his family for which he held himself responsible, drank gin—the taste of which he hated—incessantly until he began to vomit. Only by enduring this discomfort and humiliation did he believe that he had redeemed himself and could return to his normal activities.

Sometimes painful self-destructive behavior helps to refrain from actions that, according to the patient himself, are dangerously out of control. One teenager cut his hands and penis to stop masturbating - he considered this activity disgusting. He hoped that the memory of pain would prevent him from continuing to pleasure himself in such an unacceptable way.

Impulsive self-destructive actions (or threats thereof) can also be a consequence of the desire to punish another person, most often someone close. One woman regularly described her depraved behavior (often including masochistic and humiliating rituals) to her boyfriend. She had such connections only when she was angry and wanted to punish him.

And finally, self-destruction can occur from a manipulative desire to receive sympathy and help. One woman, after an argument with her partner, kept cutting her wrists in his presence, forcing him to provide her with medical attention.

Many people with BPD deny feeling pain during self-harm and even report mild euphoria immediately afterwards. Before they hurt themselves, they may feel intense stress, anger, or overwhelming sadness; afterwards they feel relief from anxiety and relief.

This relief may be due to psychological or physiological reasons, or a combination of both. Doctors have long recognized that after serious physical injury, such as a wound sustained in combat, the patient can experience unexpected calm while under a kind of natural anesthesia, despite the lack of medical attention. Some suggest that at such times the body produces biological compounds - endorphins - to self-regulate pain.

Sudden mood changes

Criterion 6. Emotional instability due to reactive mood swings with episodes of depression, irritability or anxiety, usually lasting several hours, rarely several days

The borderline personality often goes through sudden mood swings, and the episode does not last long - usually no more than a few hours. Her normal state is not calm and controlled, but rather hyperactive and wild, or pessimistic, cynical and depressed.

Audrey felt giddy joy as she covered Owen with kisses after he bought her flowers on the way home from work. While he was washing his hands before dinner, Audrey spoke on the phone with her mother, who once again reproached her daughter for not calling her to inquire about her constant illnesses. By the time Owen returned from the bathroom, Audrey had turned into a raging witch and screamed at him for not helping her with dinner. He had no choice but to sit dumbfounded and marvel at this transformation.

Always half empty

Criterion 7. Chronic feeling of emptiness

Without an internal sense of identity, borderline people often suffer from loneliness, which prompts them to look for ways to fill the “emptiness.”

Shakespeare’s Hamlet also complained about this painful, almost physical sensation: “Lately - and why, I don’t know myself - I have lost all my cheerfulness, abandoned all my usual activities; and, indeed, my soul is so heavy that this beautiful temple, this earth, seems to me like a deserted cape.”

Tolstoy defined boredom as “the desire to desire”; In this context, it can be seen that the borderline's desire to find a way to ward off boredom often ends in impulsive risk-taking, leading to destructive actions and sad relationships. In many ways, the borderline personality seeks new relationships or experiences not for their positive aspects, but to avoid feelings of emptiness, repeating the existential fates of the characters of Sartre, Camus and other philosophers.

The borderline person often experiences a kind of existential dread, which can become a major obstacle to healing, weakening the motivation to work on themselves. Many other BPD traits stem from this feeling. In this case, suicide sometimes seems to be the only reasonable way out of the eternal state of emptiness. The need to fill this vacuum or relieve boredom can lead to outbursts of rage and self-destructive impulsivity, and especially to drug addiction. Abandonment is felt more acutely, relationships suffer. It is impossible to form a stable sense of self in an empty shell. And mood instability is often caused by loneliness. Indeed, depression and feelings of emptiness often reinforce each other.

Raging Bull

Criterion 8. Inappropriate and intense displays of anger, inability to control anger, expressed in frequent displays of temper, constant rage, regular physical confrontations

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

The borderline personality's violent outbursts are unpredictable and frightening. The destructiveness of the reaction is usually completely disproportionate to the failures that caused it. Domestic rows that go as far as chasing people with a kitchen knife and throwing plates are typical manifestations of rage for a person with BPD. Anger may be triggered by a specific (and often quite trivial) grievance, but this spark ignites a whole powder keg of fear that stems from the threat of disappointment and loneliness. After a little argument about artistic styles, Vincent Van Gogh grabbed a knife and ran after his good friend Paul Gauguin with it until he flew out the door. Van Gogh then turned his rage against himself and used the same knife to cut off part of his ear.

Such powerful and flammable anger is often directed at the borderline person's immediate family: spouse, children, parents. This behavior may be a cry for help, a test of loyalty, or a fear of intimacy, but whatever its motivating factors, it alienates the borderline from those who need it most. The spouse, friend, partner or family member who stays with him despite all these attacks may be very patient and understanding or, in some cases, also extremely unstable. It is difficult to be empathetic in the face of such outbursts, and the borderline's loved ones must use all available resources to cope with the relationship (see Chapter 5).

Rage often carries over into the therapeutic setting, where psychiatrists and other mental health professionals become its targets. For example, Carrie often became angry with her doctor, constantly looking for ways to test his strength and willingness to continue working with her. In such situations, treatment becomes dangerous (see Chapter 7), and many professionals have been forced to give up working with borderline patients for this reason. Most psychoanalysts try to limit the number of their patients with BPD whenever possible.

Sometimes I act like crazy

Criterion 9: Transient, stress-related paranoid ideation or symptoms of severe dissociation

The most common psychotic experience among borderline patients is a sense of unreality and paranoid mania. The feeling of unreality implies dissociation, a separation from habitual forms of perception. The person himself or those around him seem unreal. Some BPD patients experience something like an internal split, where they feel like different aspects of their personality are coming out in different situations. Perceptual distortion can affect any of the five senses.

In some cases, borderline individuals experience temporary psychosis when faced with stressful situations (such as feelings of loneliness) or find themselves in unstructured environments. For example, psychiatrists have observed episodes of psychosis during classical psychoanalysis sessions, where there is a strong emphasis on free association and the disclosure of past traumas in an unstructured setting. Psychosis can also be caused by the use of illicit drugs. Unlike patients with psychotic illnesses such as manic schizophrenia, psychotic depression or organic illness and drug addiction, borderline psychosis is usually shorter in duration and is experienced by the patient as more acute and frightening, radically different from his usual experience. Yet to the outside world, acute psychosis in BPD may be indistinguishable from psychotic experiences in other illnesses. The main difference is the duration: within a few hours or days, the gaps in reality disappear, and the borderline person returns to normal life, unlike those suffering from other forms of psychosis.

Border mosaic

BPD is gradually being openly recognized by mental health professionals as one of the most common illnesses in the country. Professionals must be able to recognize the traits of BPD in order to effectively treat a large number of patients. Average people need to be aware of this disorder to better understand those with whom they share their lives.

As the astute reader digests this chapter, he will notice that these symptoms often appear in interaction; rather than being isolated lakes, they are more like streams that feed each other and eventually merge into rivers and then into bays or oceans. Moreover, they are also interdependent. The deep furrows left by these currents of emotion cover not only borderline people, but also parts of the culture within which they exist. The next chapter will look at how the formation of these marks in individuals affects our society.