Stormy Weather

I Hate You- Don’t Leave Me: Understanding the Borderline Personality

By Jerold J.Kreisman and Hal Straus

Psychiatrist Kreisman wrote this book (now in its third edition), when he realised there were no good manuals around on BPD - ‘a disorder that was either mostly unknown or terribly misunderstood’. Kreisman’s book, first written in 1989,  has ‘helped bring the disorder out of the shadows.’

 We’re off to a good start because the authors open with the difficulties around the BPD term. They’ve commonly used ‘the borderline’, which seems fine to me given the dictionary definition of the noun is ‘ a boundary separating two countries or areas.’ But they’ve worried that ‘the borderline’ is stigmatising, and so have tried ‘borderline individual’ or ‘person with BPD’, and even ‘an individual who has borderline personality’. Kreisman finds none of these terms satisfactory, but hasn’t yet come up with anything better. I respect his honesty and compassion.

This is a book covering many aspects of BPD - it’s part medical, part sociological, with self-help elements too. In this review, I just want to pull out the bits that caught my attention.

Diagnostics

There’s a long backstory to the clinical status of BPD (Homer, Hippocrates and the physician Aretaeus all had things to say), but that’s another story, and covered, I hope, in other books. In the recent past, the 1930s is a key period with psychoanalyst Adolph Stern’s focus on a group of patients who ‘fit frankly neither into the psychotic nor the psychoneurotic group’. It is Stern who came up with the borderline term. Whether we should be grateful to him for this is another matter. The ‘troubled personality always getting into difficulties’ (with maybe numbers  1 to 11 to distinguish between  types of troubled personality) might have done just as well. 

There are currently nine criteria for BPD, and someone needs to have at least five of these to be diagnosed as borderline/a borderline sufferer. More shortly on whether these criteria are useful, and problems establishing when a sufferer might be said to be free/“cured’ of BPD.

The nine criteria are:

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 behaviours, such as substance abuse, sex, shoplifting, reckless driving, binge eating.

5.    Recurrent suicidal threats or gestures, or self-mutilating behaviours.

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. 

 Kreisman notes that these nine criteria for BPD haven’t changed much in 40 years. If you meet five of these, you can be diagnosed borderline, but if you somehow drop down to meeting only four, you’ve been miraculously cured. This is a problem for Kreisman - ‘Such a precipitous “cure” seems inconsistent with the concept of personality.”

 Many in the field would therefore prefer to think in terms of degrees of BPD - of how much an individual is impaired by the nine defining criteria above. This is a dimensional approach (BPD along a spectrum), and would allow better tracking, it’s argued, of improvement from symptoms.

Emotional haemophilia 

Kreisman describes borderline types as suffering from ‘emotional haemophilia’ - an interesting characterisation. We lack ‘the clotting mechanism needed to moderate…spurts of feeling.’

I found this quite useful. It made me realise that many of the strategies in DBT (Dialectical Behaviour Therapy) can work as clotting agents, but really only if practised regularly, and with commitment.

A hopeful approach 

This is one of the more hopeful books I’ve read on BPD. The author refers to sufferers ‘maturing out’ of their symptoms (with far fewer people diagnosed after their mid-forties). This improvement may falter in later life though, as people face the challenges of ageing.  All the more reason, then, for helpful therapies to be readily available for older populations (they often aren’t). A link to a rare study of BPD treatment of this group can be found here.

 Abuse and BPD

Most BPD sufferers have experienced maltreatment (emotional, physical, sexual) in childhood. Kreisman writes that ‘case histories of borderline patients are typically desolate battlefields, scarred by broken homes, chronic abuse, and emotional deprivation.’

There is also a genetic base to the over-sensitivity and impulsivity that characterises BPD, and this heritability factor interacts with the risk factors of maltreatment. 

The chapter ‘Roots of the Borderline Syndrome’ covers developmental aspects of BPD in interesting detail. I found chapter four - The Borderline Society - which focuses on the current fragmentation of all aspects of society less engaging (perhaps it reminded me too much of my own desolate feelings), but the point made is a good one - would a  structured society keep its more damaged citizens in better mental health? Or stop them deteriorating? 

 Treatment  

The remainder of this book (which covers a lot of ground) looks at ways to engage with, understand and treat BPD. Kreisman discusses the SET-UP theory of communication - an intervention he developed to help contain the extremes of borderline distress. SET-UP’s pillars are Support, Empathy, and Truth.

There’s a very good chapter on specific therapies for BPD, which includes some I’ve not heard of, such as Gunderson’s Good Psychiatric Management, which he created when he realised that most BPD sufferers didn’t have access to specialised therapies, and practitioners anyway didn’t have the expertise to help. I really like his principles, which include Be thoughtful, Be flexible and pragmatic and, Expect change.

 Kreisman notes that of all the psychological problems out there, BPD is the only one where therapy, and not drugs, is the recommended response. He emphasises that therapy outcomes for BPD are generally positive. This is encouraging, but it comes with some provisos. Some features of BPD are easier to treat than others. The defining symptoms of BPD such as suicidality and destructive impulsiveness respond more quickly to treatment than symptoms linked to temperament - fears of abandonment and feelings of emptiness. So even though BPD is no longer a ‘dustbin diagnosis’, struggles remain for the sufferer. I like this realism, which fits with my own experience.

A final gem from this impressive book - Freud’s famous collection of hysterics - ‘The Wolf Man’, ‘The Rat Man’, ‘Little Hans’, and ‘Anna O’ would most likely now be diagnosed as borderline.