Borderline PD

From The Last Psychiatrist - October 23, 2007

The Diagnosis of Borderline Personality Disorder: What Does It Really Mean?

A diagnosis of borderline personality disorder could, theoretically, mean that the psychiatrist made a serious attempt at evaluating defense mechanisms and ego integrity; or at least a matching of symptoms to DSM criteria. It's theoretically possible, yes. Other things that are theoretically possible include alien abduction, peace in our time, dual eigenstates, user friendly Movable Type upgrades, political discussions that don't rely on information from John Stewart, Daleks, recession with low unemployment, Independents, Madonna/whores, a benignly rising Russia.

Let's assume there's a difference between a diagnosis and a heuristic.

A diagnosis is based on pathology, or at least on a set of predetermined criteria. I diagnosis must be both reliable-- multiple doctors would find the same diagnosis when given the same information, and valid-- the diagnosis actually is the thing you say it is.

Many psychiatrists devalue diagnoses into heuristics, that is, they have intuitive "rules of thumb" that are extensions of their own cognitive biases. This isn't automatically good or bad; the heuristic is only as helpful as the bias. For example, if the last ten people who you saw that smoked crack also had syphilis, on the 11th you might apply the heuristic, "where there's crack, so there be syphilis, better get a blood test." Unfortunately, it could be applied the other way: the 11th patient with syphilis you see gets prejudged as a crack addict.

The diagnosis of a personality disorder is supposed to be valid, it's supposed to mean something. However, in general they are diagnosed very unrigorously, if such a thing can be imagined of psychiatrists. They carry nearly none of the implications of causality (except, once in a while, sexual abuse), nor do they reflect a distinctive understanding of a person's personality (e.g. borderline as distinct from narcissism.)

A good example is borderline. If a psychiatrist calls it borderline, it may or may not be, actually, borderline personality, a la Kernberg. So if a patient happens to know she was diagnosed with borderline (which she rarely will-- it's kept secret or encoded as "bipolar") it doesn't mean she can look it up on the internet for more information, because that's not what the psychiatrist meant by the diagnosis. "Articulate" has a certain meaning, look in the dictionary; it is fairly consistent throughout all settings except one: when it is used by a white guy to describe a black guy. In that case, the word suddenly means something completely different than it ordinarily does: it means "not hung up about race." Here's the point: the black guy may actually be articulate, or not be articulate-- who knows? But white people know exactly what it means in that context. Similarly borderline: you may, indeed, have a borderline personality, or may not; but the diagnosis to the psychiatrist means something else. n other words, it's not at all a diagnosis, it's a heuristic.(1)

Devoid as these personality disorder heuristics are of their originally intended meanings, they do, however, reliably imply the same things to other psychiatrists. Those "things" however, are uncoupled from the "official" diagnosis. The heuristic may have a lot, or absolutely no, relationship to the diagnosis. In other words, the term "borderline" is immensely reliable among psychiatrists, but not at all between psychiatrists and non-psychiatrists, who think it means something else. What psychiatrists should have done is invented their own special word for the heuristic of "borderline." But they're lazy.

So, as a public service, I'll tell you what psychiatrists mean when they say borderline. Once again, I'm saying that this is how the diagnosis is used by many psychiatrists. If you email me and say that I'm a jerk for not understanding the term, then you need to go buy yourself a helmet.

First, borderline is a heuristic of countertransference: if the psychiatrist feels frustrated, or exasperated, then the patient is borderline.

Second, borderline is meant as a synonym for any of the following: needy, argumentative, touchy/hypersensitive.

Third, it is generally reserved for the following four types:

1. Very attractive female, who comes for problems the psychiatrist considers ordinary: men, work/school, problems with parents, etc. It is diagnosed here most often by female psychiatrists, and carries the connotation: "Grow up."
2. Overweight, typically white, female, who needs/wants benzos, especially Klonopin. The implications are lack of self-control, and reliance on external supports.
3. Thin female with a lot of anger. By example, the woman who comes for treatment of "depression" but describes most life events in terms of attacks, sleights, harm, etc-- i.e. power differentials.
4. Gay man.

If you are a patient, my point in telling you this iss not "why did they diagnose me with borderline?" but rather, "oh my God, are you telling me he thinks I'm borderline just because I told him if I don't get my twice a day klonopins, I'll freak out?"

Again, these aren't even accurate descriptions of the formal diagnosis borderline; number 3, for example, is better described as narcissism, especially when anorexia (restricting type) is involved. But her anger makes the psychiatrist uncomfortable, so it gets labeled as borderline.(2) I hope you see two obvious problems: first, the term is used pejoratively; but, more importantly, giving something a label alters the environment, in this case in the wrong way. The above #3 female doesn't need limit setting, she needs mirroring transference, etc. (And don't forget about the narcissistic injury.)

But again, even though the term is used improperly and probably leads to worse treatment for the patient, it does mean the same wrong thing to most psychiatrists. So when I'm being referred a "30 year old borderline," I know almost exactly what I'm getting, even though it has nothing to do with borderline. Frustrating? You betcha.

But the sleight of hand is that it sounds like personality disorders are crappy and unreliable diagnoses and have little in common with their original meaning. In fact, most psychiatric diagnosis are equally crappy and unreliable. When you read articles saying "borderline is a pejorative term, and these patients are often really bipolar" what you need to understand is that "bipolar" is not a more valid or reliable diagnosis, it's simply another heuristic. It isn't less pejorative, it isn't more "real." It carries a different set of implications, but it isn't a more rigorous, more "biological" classification. It's not like saying, "it's not a unicorn, it's a rhinoceros." It is like saying, "it's not a unicorn, it's a pegasus."

This, by the way, is the reason why so many defenders of psychiatric diagnoses can't accept that "borderline" and "bipolar" are equally subjective terms. They say, "the diagnosis of borderline has very poor inter-rater reliability; bipolar has high inter-rater reliability." But reliability is not the same as validity. If you take twenty thousand members of the KKK, and ask them to "diagnose" the problem of contemporary society, their answer will be the same, i.e. reliable. But it's wrong, obviously. The diagnosis of bipolar is reliable, but in the same way as the KKK's diagnosis of society's ills was reliable. It may be completely wrong, it may be completely right, it may be partly right, partly wrong, in some cases but not others, etc.

If you want to know why I've used racial analogies throughout this post, it's because these are all, in essence, prejudices. "It's bipolar." "It's borderline." "It's poverty." "It's bad parenting." "It's..." Well? It's not really any of those after all, is it?


January 5, 2007
Borderline

Narcissism- what I believe to be the primary disease of our times-- is one side of a coin. The other side-- the narcissist's enabler-- is the borderline.

If the analogy for narcissism is "being the main character in their own movie," then the analogy for borderline is being an actress.


Note the difference: the narcissist is a character: an invented but well scripted, complete with backstory, identity. The narcissist is trying to be something-- which already has a model. Perhaps he thinks himself an artist type, or a tough guy, or the type interested in spiritualism, or like the guy in the Matrix. Types, characters. The borderline is no one: the borderline waits for the script to define her.

Her? Yes. Narcissists are mostly hes, and borderlines hers. (Not always, sure.)

The classic description includes: intense, unstable relationships; emotional lability; fear of abandonment. The borderline has no true sense of self.

Ironically, the borderline is a borderline only in relationship to other people. The borderline has a problem with identity only because other people in the world have stronger identities. Your Dad wants you to be one way, so you do it. Your boyfriend wants a different woman; so you do it. Your husband wants something else; so you do it. Who the hell are you, really? You have no idea, because you are always molding yourself based on the dominant personality in your life.



This si done mostly out of fear of abandonment: if you don't "be" the person they want, then they'll leave you, and then what? (Borderlines don't end relationships-- they end relationships for another relationship.)

The narcissist creates an identity, then tries to force everyone else to buy into it. The borderline waits to meet someone, and then constructs a personality suitable to that person.

If a borderline is dating a guy who loves the Dallas Cowboys, then for sure, she will love the Dallas Cowboys. If, however, she breaks up with him, and then dates a guy who loves the Giants, then she'll love the Giants. But here's what makes her a borderline: she will actually believe the Giants are better. She's not lying, and she's not doing it for him; she actually thinks she thinks it's true. Everyone else on the outside sees that it is obviously a function of whom she's dating, but she is sure she came up with it on her own. And she's not play acting: at that moment that she believes, with every fiber of her being, that the Giants are better.

Here's the ironic part: if a borderline was shipwrecked on a desert island with no one around, she'd develop a real identity, of her own, not a reaction to other people. Sorry, that's not the ironic part, this is: she'd become a narcissist.

The bordeline has external markings of identity: tattoos, changing hair colors, clothes. You may recall I said almost the same thing about the narcissist: the difference is, of course, the borderline changes her image as she changes her identity-- in other words, as she cahges the dominant personality in her life; but the narcissist crafts a look, an identity, which he then defends at all costs: "I would sooner eat fire ants than shave my mustache." Of course. Of course.

All those silly movies about a woman moving away, or to the big city, and she "finds herself:" that's a borderline becoming a narcissist.

If you look back on past long term relationships you've had, and are completely perplexed as to what on earth you ever saw in each of those people that kept you with them for a year; well, there you go.

This is why narcissists marry borderlines, and not other narcisstists. Two narcissists simply can't get along: who is the main character? Meanwhile, two borderlines can't be with each other-- who supplies the identity? The narcissist thrives with the borderline because she provides for him the validation that he is, in fact, the lead; the borderline thrives with the narcissist because he defines her. And, as she will tell you every single time, without fail: "you don't know him like I do." Everyone else judges his behavior; but the borderline is judging his version of himself that she has accepted.

Go back to my white high heel shoes example. The narcissist demands his woman wear white high heel pumps not because hem ay like them himself-- he might or might not-- but because he is the type of man that would be with the type of woman who wears white pumps. He thinks he's the sophisticated, masculine man of the 1980s, so she damn well better be Kim Bassinger from 9 1/2 Weeks. Blonde hair, white pumps. She could weight 400lbs, that's not the point (though it will become one later.) So she wears the shoes, and starts to believe she likes them, starts to believe that she is that woman. He reinforces this with certain behaviors or language towards her (he'll open the door for her, push her chair in, etc. You say, "well, what's wrong with that? Nothing, except that he ALSO beats her when she doesn't wear the shoes.)

It's almost battered-wife syndrome: what keeps her with tat maniac is that when he's not beating her, it seems like he is actually being kind to her, so great is the difference between being beaten and simply not being beaten. Meanwhile everything he does wrong has an external explanation: it was the alcohol, he's under stress, etc. And she's doing this rationalizing for herself, not for him, because it is vital to her own psychological survival that he actually be who he says he is, that he actually have a stable identity that things happen to, because her identity depends on his being a foundation.

That's why the therapist has to maintain such neutrality, consistency in the sessions. It's not just to avoid conflicts; by being the most dominant (read: consistent) personality, the borderline can begin to construct one for herself using the blueprints of yours as a guide.

If the borderline sounds like a 15 year old girl, that's because that's what she is. The difference, of course, is the actual 15 year old girl is supposed to be flaky, testing identities and philosophies and looks until she finally lands on the one that's "her." But if you're 30 and doing that, well...



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(BTW, if you want to understand the mystery of women's addiction to shoes, here's my take: shoes are the article of clothing that represent possibility. Each shoe is a different look, a different character, and she can select "who" she wants to be that day. You might not notice the difference, but she feels it. This is not borderline-- it's normal, but it's normal because the shoe changes and the rest of her doesn't.)