Kriesman (2010) notes the apparently paradoxical presentation of borderline personality disorder in the patient. On the one hand, they can initially appear domineering, confident and in control. Just as quickly, however, their persona can become meek and even childlike. Indeed, they can oftentimes give off an intimidatingly sophisticated and omnipotent exterior, only to lapse into an almost infantile persona Their weight oftentimes violently fluctuates, and their sleeping pattern becomes disrupted. In the example he uses, a female patient who had been diagnosed with BPD grew up the daughter of a highly demanding pastor. He describes her as fearful of her father’s draconian demands, yet also desperate to please him.
In college, he reports that this patient would violently oscillate between extreme dysphoria and manic elation, in a way reminiscent of bipolar disorder. Although oftentimes ebullient and friendly, she would sometimes explode with rage towards close friends. Typical of the borderline, she was quite promiscuous and desperate for the attention of men, all the while conscious of tricking them. Such a borderline can oftentimes derive her identity from the attention she receives from men, although the borderline oftentimes sabotages the relationship, Kriesman notes, with their high-conflict personality. That is, the borderline oftentimes deliberately stirs up drama and conflict within the relationship, driving the individual away. He notes that they sometimes do this simply in order to get attention of which they feel deprived.
The borderline patient described a kind of split personality that would cause her to become unusually promiscuous and unfaithful to her mate. Solitude oftentimes causes the borderline to feel worthless; an anxiety, Kriesman notes, which can drive them to compulsive and destructive behavior patterns, such as binge eating or drug abuse. The case of the borderline, he notes, is quite tragic. They are very fragile individuals who (like all of us) are desperate for love, yet deathly afraid of others becoming too close. The borderline oftentimes will explode in paranoid fits of accusation, only to come back soon after as though nothing unusual had transpired. They may seem very friendly at one moment, only to become icy and distant. Thy make break up with their mate one day, and come back later that day insisting on getting back together. They may oscillate violently between guilt and self-blame to rage and blaming others. This kind of paradoxical behavior is one of the most distinctive and difficult symptoms of BPD.
The frequency of BPD is disturbingly high: “Approximately 10 percent of psychiatric outpatients and 20 percent of inpatients, and between 15 and 25 percent of all patients seeking psychiatric care, are diagnosed with the disorder. It is one of the most common of all of the personality disorders”(Kriesman, 2010). The term comes from the notion that the borderline is “borderline”-psychotic; less than psychotic but more seriously mentally ill than the garden-variety neurotic.Various comorbidities are common with BPD, with as many as half of those with eating disorders and half of those diagnosable as drug addicts suffering from the disorder (Kriesman, 2010). Coined in the 1930s, it did not receive “official” status until the publication of the DSM-III in 1980.
Tragically, suicide attempts, oftentimes successful, are common among those with BPD. Over half of those with the disorder attempt suicide, and around 10 percent of them succeed. This is especially the case among individuals who have an unhealthy family life and lack of social support (Kriesman, 2010).
Like other personality disorders, BPD tends to manifest itself in early adulthood (Kriesman, 2010). While some favor a dimensional approach, according to which one can suffer with varying degrees of severity with borderline personality disorder, Kriesman notes that BPD is diagnosed according to “categorical paradigms”, according to which “several symptoms have been proposed to be suggestive of a particular diagnosis, and when a certain number of these criteria are met, the individual is considered to fulfill the categorical requirements for a diagnosis”(2010). The DSM-IV contained 9 symptoms, with a diagnosis being appropriate if 5 were met:
1. Frantic efforts to avoid real or imagined abandonment. 2. Unstable and intense interpersonal relationships. 3. Lack of clear sense of identity. 4. Impulsiveness in potentially self-damaging behaviors, such as substance abuse, sex, shoplifting, reckless driving, binge eating. 5. Recurrent suicidal threats or gestures, or self-mutilating behaviors. 6. Severe mood shifts and extreme reactivity to situational stresses. 7. Chronic feelings of emptiness. 8. Frequent and inappropriate displays of anger. 9. Transient, stress-related feelings of unreality or paranoia.
These symptoms, Kriesman notes, can be grouped into 4 categories:
1. Mood instability (1, 6, 7 and 8)
2. Impulsivity and dangerous uncontrolled behavior (4, 5)
3. Intepersonal psychopathology (2, 3)
4. Distortions of thought and perception (9)
The way the DSM-V articulates BPD is somewhat modified
Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive selfcriticism;
chronic feelings of emptiness; dissociative states
b. Self-direction: Instability in goals, aspirations, values, or
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings
and needs of others associated with interpersonal
hypersensitivity (i.e., prone to feel slighted or insulted);
perceptions of others selectively biased toward negative
attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close
relationships, marked by mistrust, neediness, and anxious
preoccupation with real or imagined abandonment; close
relationships often viewed in extremes of idealization and
devaluation and alternating between over involvement and
B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional liability: Unstable emotional experiences and
frequent mood changes; emotions that are easily aroused,
intense, and/or out of proportion to events and
b. Anxiousness: Intense feelings of nervousness,
tenseness, or panic, often in reaction to interpersonal
stresses; worry about the negative effects of past
unpleasant experiences and future negative possibilities;
feeling fearful, apprehensive, or threatened by uncertainty;
fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears
of excessive dependency and complete loss of autonomy.
d. Depressivity: Frequent feelings of being down, miserable,
and/or hopeless; difficulty recovering from such moods;
pessimism about the future; pervasive shame; feeling of
inferior self-worth; thoughts of suicide and suicidal
2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response
to immediate stimuli; acting on a momentary basis without
a plan or consideration of outcomes; difficulty establishing
or following plans; a sense of urgency and self-harming
behavior under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and
potentially self-damaging activities, unnecessarily and
without regard to consequences; lack of concern for one‟s
limitations and denial of the reality of personal danger.
3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or
irritability in response to minor slights and insults.
One of the most common complaints of the borderline is continual complaints of emptiness. Such an experience is so dysphoric that it oftentimes causes the borderline to wreckless behavior in a desperate attempt to feel something rather than nothing. Such impulsivity is oftentimes the result of a desire for a kind of limit-experience which obliterates consciousness of their pain, and, to paraphrase Kriesman, returns them to a kind of emotional infancy.
“During periods of intense loneliness and emptiness, the borderline will go on drug binges, bouts with alcohol, or sexual escapades (with one or several partners), sometimes lasting days at a time. It is as if when the struggle to find identity becomes intolerable, the solution is either to lose identity altogether or to achieve a semblance of self through pain or numbness”(Kriesman, 2010).
Kriesman further describes the borderline as afflicted with a kind of “emotional hemophilia,” referring to their tendency to lash out at very minor real or imaginary slights.
Perhaps most central to the borderline patient, from an egoic perspective, is a lack of identity:
“When describing themselves, borderlines typically paint a confused or contradictory self-portrait, in contrast to other patients who generally have a much clearer sense of who they are. To overcome their indistinct and mostly negative self-image, borderlines, like actors, are constantly seatrching for “good roles,” complete “characters” they can use to fill their identity void. So they often adapt like chamaleons to the environment, situation, or companions of the moment…”(Kriesman, 2010).
While genetic and neurobiological abnormalities may play an important role in the development of borderline personality disorder, it is undeniable that family environment plays a very important role.
“The family background of a borderline is often marked by alcoholism, depression, and emotional disturbances. A borderline childhood is frequently a desolate battlefield, scarred with the debris of indifferent, rejecting, or absent parents, emotional deprivation, and chronic abuse. Most studies have found a history of severe psychological, physical or sexual abuse in many borderline patients. Indeed, a history of mistreatment, witness to violence, or invalidation of experience by parents or primary caregivers distinguishes borderline patients from other psychiatric patients”(Kriesman, 2010).
He notes that this instability oftentimes continues into the adult lives of the borderline, where their romantic relationships become tumultuous and transient. Although the borderline may have longer-term relationships, these are oftentimes quite tumultuous as well.
Trapped in a psychically infantile and primitive emotional state, the borderline experiences extreme ambivalence and anxiety when faced with realities in which perceptive nuance is required. In other words, the borderline engages in what psychoanalysts refer to as “splitting,” or black-and-white thinking. It is this tendency that is responsible for much of the borderline’s emotional instability and inconsistency. The borderline’s lover is either a devil or an angel, oftentimes in the same day; a Madonna or a whore, oftentimes in the same day; a saint or an abuser, oftentimes in the same day. In other words, they are alternatively idealized or devalued, and all of this may happen several times in a day or a weak. Mild disappointments become extreme devaluations, and minor achievements may catapult the lover to unprecedented heights of virtuosity in the eyes of the borderline. There is no gray area. Only black and white:
“This kind of behavior, called “splitting,” is the primary defense mechanism employed by the borderline. Technically defined, splitting is the rigid separation of positive and negative thoughts and feelings about oneself and others; that is, the inability to synthesize these feelings. Most individuals can experience ambivalence and perceive two contradictory feeling states at one time; borderlines characteristically shift back and forth, entirely unaware of one emotional state while immersed in another. Splitting creates an escape hatch from anxiety: the borderline typically experiences a close friend or relation…as two separate people at different times”(Kriesman, 2010).
Borderlines, in their search to escape intolerable loneliness, oftentimes end up with inappropriate and abusive partners. Even taking abuse may be tolerable to the borderline, comparable to the extreme pain of loneliness and lack of the kind of identity which such a partner, even an abusive one, may confer (Kriesman, 2010). This further shores up the borderline from their intense fear of abandonment. Unfortunately, as is typical of their tendency towards splitting, giving the borderline too much affection or attention may cause her to push the individual away. It should therefore come as no surprise that the borderline typically struggles a great deal with the question of how to manage and establish appropriate boundaries.
Antidepressants, especially serotonergic ones, are oftentimes helpful in treating anxiety (as many of them double as potent anxiolytics), impulse-control problems (particularly when it comes to treating the tendency of borderlines to have fits of explosive rage and aggression), sensitivity to rejection, and symptoms of depression such as the chronic emptiness of which the borderline frequently complains (Kriesman, 2010). Monoamine oxidase inhibitors (MAOIs) have also shown promise, although tricyclic antidepressants (TCAs) have been shown to be less effective, and may even decrease their already tenuous control of emotions.
Mood stabilizers may increase mood stability, help with anxiety, impulse-control and anger, but not many studies have been conducted when it comes to their efficacy in treating BPD (Kriesman, 2010). The combination of certain antipsychotic or neuroleptic medication with SSRIs may have effects similar to those of mood stabilizers. While anti-anxiety medication can be helpful, it ought to be remembered that borderlines are prone to difficulty with impulse-control and substance abuse, and so they may be contraindicated for treatment. This is especially the case with benzodiazepines.
Kreisman MD, Jerold J.; Hal Straus (2010-10-25). I Hate You–Don’t Leave Me: Understanding the Borderline Personality (Kindle Location 142). Penguin Group US. Kindle Edition.