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Sometimes I Act Crazy

John Wiley & Sons

Chapter One

There is in every one of us, even those who seem to be most moderate, a type of desire that is terrible, wild, and lawless. -Plato, The Republic

Borderline Personality Disorder (BPD), the most common personality disorder seen in clinical settings, is excruciatingly painful to live with-both for the sufferer and those closest to him. Yet despite the prevalence of BPD, it may be the most misunderstood and underdiagnosed mental illness. This chapter provides a broad discussion of the disorder-from biological, genetic, and environmental causes, to the most current DSM diagnostic criteria, to the various forms of psychotherapeutic and medical treatments. The obstacles to properly diagnosing BPD, such as its stigma within the mental health profession and the vagaries of insurance coverage, also are examined. A "BPD Checklist" gives the reader a chance to detect BPD's early warning signs in himself and others.

Diana

In many ways Diana was a typical girl: she loved to play with her dolls and like her friends dreamed of someday marrying her Prince Charming, who would whisk her off to his castle, where they would live happily ever after. But somewhere along the way, Diana veered into a different dimension. She crossed the boundary from "ordinary"into borderline.

This change in direction might have been influenced by her mother, who was very close to Diana and who abruptly walked out on the family when Diana was six years old. Her father was left to rear the children, but he was emotionally and often physically distant, leaving Diana and her siblings in the care of a nanny. Diana would be frantically anxious when he was gone, inquiring constantly as to when he would return.

Periodic visits with her mother left both Diana and her mother in tears. During this time, Diana became more moody and insecure. She was afraid of the dark and of being alone. She was very sensitive and would cry easily. She clung to her menagerie of stuffed animals, which she called "my family." Diana tried desperately to please both of her parents, while secretly blaming herself for their divorce. She felt she was not good enough to keep them together and developed a fear that everyone she loved would eventually abandon her.

When she was fifteen, Diana became more concerned about her appearance and, like her older sister, began to induce herself to vomit after eating. She entered into a pattern of anorexia and bulimia, which intermittently plagued her for the rest of her life. The fractures in Diana's personality became more prominent during her adolescence. She could be charming, charitable, and remarkably empathic with friends at times, but on other occasions she exhibited an unpredictably cruel rage when these same friends disappointed her. Sometimes, during stressful periods, she appeared calm and stoic, but at other times she became irrationally emotional, alternating between inconsolable grief and ferocious anger.

At twenty, Diana married her prince-Prince Charles of England. Yet Princess Diana did not live happily ever after. As her fairy-tale marriage disintegrated, so did her manufactured facade of equanimity. She became more overtly impulsive and self-destructive. She threw herself into her charity work, perhaps hoping to derive for herself the kind of caretaking she was bestowing on others. The affliction of borderline personality plagued Princess Diana until her untimely death in 1997.

Advances in Diagnosis and Treatment

Our previous book, I Hate You, Don't Leave Me: Understanding the Borderline Personality, originally published in 1989, was one of the first attempts to help those afflicted with Borderline Personality Disorder (BPD) to understand and cope with the condition. At that time, understanding of this disorder was in its infancy. Research studies were scarce, and the few that did deal with the subject lacked the advantage of studying patients over long periods of time. Ideas on the root causes of the disease were more speculation than scholarship. Technology revealing the relationship of brain physiology to behavior and mental illness was still primitive.

The concept of borderline personality was insufficiently understood and accepted-even among those professionals trained to recognize and treat it. Many clinicians were hesitant to accept the newly defined concept and relegated it to the status of "wastebasket diagnosis"-a label to be used when the doctor simply did not understand the patient or could not "fit" the patient's symptoms into any other, more acceptable disorder. In many therapeutic settings the term became a diagnosis of frustration: a difficult patient who was uncooperative; demanding; clinging; confusing; angry; or, most important, failed to respond to the psychiatrist's ministrations was often labeled "borderline."

Structured treatment strategies also were in primordial stages. Psychotherapeutic techniques and medications used to treat related disorders generated inconsistent results when applied to BPD. Outcome studies following therapy interventions were minimal.

It is no wonder, then, that many readers of I Hate You came away from the book feeling that the prognosis for borderlines was dismal. Though they could understand what they-or their friends or family-were experiencing, some readers concluded that there was little hope for a cure. One reader wrote that although she found most of the book "informative and helpful, I was still left in tears at the end of it because of the gloomy outcome it suggested."

So what has changed over the past fourteen years? Breakthroughs on many fronts have led to significant leaps in our understanding and treatment of BPD. Geneticists, exploring the effects of individual chromosomes, have connected specific borderline behaviors to discrete locations on the genome. Scientists have discovered biochemical and anatomical alterations in the brain that are correlated with BPD behaviors. Psychotherapeutic techniques have been developed specifically to treat borderline patients, and new medications are more effectively controlling symptoms. Just as the synthesis of therapy and medication has provided relief for those suffering from schizophrenia, bipolar disorder, anxiety disorders, and depression, the same has happened with treatment approaches to BPD. All of these advances have greatly improved the prognosis for these patients. In short, people with BPD can-and do-get better!

Epidemiology and Demographics

BPD is the most common personality disorder seen in clinical settings, both in the United States and in cultures throughout the world. Depending on the study, BPD comprises between 30 and 60 percent of all patients diagnosed with any of the ten defined personality disorders. The prevalence of BPD in the general population, as strictly defined in the fourth and most recent revised edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV-TR), is conservatively estimated to be 2 to 4 percent. Many clinicians believe the real percentage to be higher. Most other countries apply the DSM in defining psychiatric illnesses and find similar results, confirming that BPD is not confined to Western cultures.

Approximately 10 percent of the entire clinical population evaluated in outpatient mental health clinics, and more than 20 percent of all inpatients, satisfy BPD criteria. Three times as many women as men are diagnosed with BPD, a prevalence that has remained stable over the past two decades. Patients with the diagnosis of BPD are more likely to receive all forms of psychosocial therapy and to utilize more psychotropic medications than patients with depression or any other personality disorder.

The intensity of borderline symptoms may be related to life situations. One large study indicated that more severe pathology was correlated with students or the unemployed, separated (but not divorced) individuals, atheists, people with a criminal record, and those who lost a parent through death or divorce. These associations held for blacks and whites equally. There was no correlation with the level of education.

The Borderline Life Cycle

Typically, borderline behavior is first observed from the late teens to the early thirties, though severe separation problems or rage outbursts in younger children may be harbingers of the diagnosis. A borderline state may emerge from a parental relationship that is at one of two extremes-either too dependent or too rejecting. As described in detail in our previous book, disruption of normal child development, particularly during the crucial rapprochement age (sixteen to twenty-five months), may hinder development of a constant, separate identity, one of the prominent symptoms of BPD.

Most adolescents are already grappling with such issues as identity, moodiness, impulsivity, and relationship insecurities that are at the core of BPD. (Indeed, some might argue that the term "borderline adolescent" is a redundancy!) However, normal, volatile adolescents do not exhibit suicide attempts, violent rages, or excessive drug abuse observed in borderline teenagers.

During their third and fourth decades, many borderlines achieve some stability in their lives. Borderline behaviors may be curbed or no longer significantly hamper daily activities. Thus many former borderlines, with or without treatment, may emerge from the chaos of their lives to a relatively stable midlife functioning that no longer satisfies defining criteria for the BPD diagnosis. BPD does persist in the elderly but at a much lower rate.

Crossing the Border: A Brief Historical Background

The term "borderline" was first employed more than sixty years ago to describe patients who were on the border between psychotic and neurotic but could not be adequately classified as either. Unlike psychotic patients, who were chronically divorced from reality, and neurotic patients, who responded more consistently to close relationships and psychotherapy, borderline patients functioned somewhere in between. Borderlines sometimes wandered into the wild terrain of psychosis, doctors observed, but usually remained for only a brief time. On the other hand, borderlines exhibited several superficial neurotic characteristics, but these comparatively healthier defense mechanisms collapsed under stress.

Over the years, such terms as "pseudoneurotic schizophrenia" and "as-if personality" were employed to describe the condition. Revisiting some of Freud's early case histories of neurosis, many theorists reinterpreted such cases as "The Wolf Man" and "Anna O." as examples of borderline functioning. For decades psychiatrists recognized the existence of this "border" illness but were unable to arrive at a consensus definition. Finally, in 1980, the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III) classified the BPD diagnosis, for the first time utilizing specific, descriptive symptoms.

Defining BPD

Borderline Personality Disorder is the most prominent of the ten personality disorders defined and described in DSM-IV-TR. A "personality disorder" is defined as a cluster of long-standing, ingrained traits in an individual's demeanor. Typically detectable by the time of early adulthood, adolescence, or even earlier, these traits are relatively inflexible and result in maladaptive, destructive patterns of behaving, perceiving, and relating to others. The diagnoses of personality disorders are separated from those of most other psychiatric illnesses by placement on a separate classification level (Axis II). Other psychiatric illnesses, such as depression, schizophrenia, substance abuse, and eating disorders, are defined on Axis I. Whereas Axis II personality disorders are perceived as long-standing, chronic maladaptations in behavior, Axis I afflictions are traditionally seen as time-limited, more biologically based, and more amenable to medications. Axis I symptoms usually recede, allowing the person to return to "normal" functioning between exacerbations of illness. People with diagnosed personality disorders usually continue to express characteristics of the dysfunction even after the acute problem resolves. Cure usually requires a longer time, since it involves significantly altering enduring behavior patterns. Personality disorders, especially BPD, have been demonstrated to elicit more severe functional impairment in day-to-day living than some Axis I disorders, including major depression.

BPD shares several characteristics with other personality dysfunctions, especially histrionic, narcissistic, antisocial, schizotypal, and dependent personality disorders. However, the constellation of self-destructiveness, chronic feelings of emptiness, and desperate fears of abandonment distinguish BPD from these other character disorders.

The primary features of BPD are impulsivity and instability in relationships, self-image, and moods. These behavioral patterns are pervasive, usually beginning in adolescence and persisting for extended periods. The diagnosis, according to the DSM-IV-TR (and generally accepted worldwide), is based on the following nine criteria. An individual must exhibit five of these nine symptoms to receive the BPD diagnosis.

BPD Criteria

1. Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. Identity disturbance: markedly and persistently unstable self-image or sense of self

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)

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

6. Affective (mood) instability and marked reactivity to environmental situations (e.g., intense episodic depression, irritability, or anxiety usually lasting a few hours and rarely more than a few days)

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9. Transient, stress-related paranoia or severe dissociative symptoms (feelings of unreality)

As we will see when we examine these criteria more closely in later chapters, the latest DSM-IV-TR makes only minor revisions to defining symptoms. The most significant change is the addition of the ninth criterion, which recognizes occasional, fleeting episodes of psychosis.

Continues...

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Excerpted from Sometimes I Act Crazy by Jerold J. Kreisman Hal Straus Excerpted by permission.
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