Borderline personality disorder
(A) Significant impairments in personality functioning manifested by:
1. Impairments in self-functioning (a or b):
(a) Identity: markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
(b) Self-direction: instability in goals, aspirations, values, or career plans
AND
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 feeling 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 withdrawal.
(B) Pathological personality traits in the following domains:
1. Negative affectivity, characterized by:
(a) Emotional lability: unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
(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 behavior.
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.
(C) The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
(D) The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
(E) The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition.
Throughout its short history, BPD has been a controversial diagnosis [3], criticized for its weighted construction, its inconsistent and unclear meaning, and its uneven, stigmatizing, and punitive application [7]. Studies cite BPD rates of approximately 0.4–1.8 % among community samples [8, 9] and 10–25 % among clinical samples [10, 11]. BPD is more often diagnosed in women, which estimates that approximately two thirds to three quarters of those diagnosed with BPD are women [12, 13].
The basis of diagnostic prevalence alone (75 % of those diagnosed with BPD are women) invites us to consider the possibility that it might be a gendered diagnosis. Dana Becker [14] argues that the borderline diagnosis has been “feminized” and that BPD has become a new “female malady” for the late twentieth century.
One of the main features on the borderline is the patient’s unstable, fragmented or missing self. People deemed borderline are not only placed “on the borders,” at the edges of sanity; they are also placed at the very margins of selfhood [15]. Their selves are described as “empty” [16], “dead” [17], “unstable” or “split” among “part-selves” [18], as containing a “defect in the organizing structure of the self” [19]; such patients manifest a “blurring of ego boundaries” (confusion between one’s own thoughts and feelings and those of others) [20].
Butler critiques the pre-social conceptions of identity and subjecthood and argues about the inseparability of gender and identity. They cannot be separated; to speak of “selves” necessarily draws one into a consideration of gender. Butler calls into question the neutrality and universality of the notion of “self.” Her analysis (a part of the feminist critique of the gendered quality of self) has shown how conceptions of the self or subject are conflated with conceptions of masculine subjectivity, reflecting the experiences, desires, and illusions of this masculine position [21]. Some authors refer to women having been constructed as “other,” over-determined by their feminine position in the gender binaries of patriarchal logic [22–24].
Within this binary logic of the self and the other and of masculine and feminine, the status of feminine identity is unstable, marked by paradox and contradiction. Women are in a representational and experiential double bind, between the traditional essentialist feminine identity, on the one hand, and the psychologically defined norm or ideal of healthy, normal selfhood, on the other. Ambiguity and confusion surround this double bind [15].
Men are in the minority of patients receiving the diagnosis of BPD; 25–30 % of those diagnosed are males [14]. One of the explanations offered for the low numbers of men diagnosed as borderline is that men showing similar traits to borderline women tend to be diagnosed as sociopathic, or as having antisocial personality disorder [25]. According to this view, some male patients may express the same confusion and uncertainty or instability and rage as women, but tend to direct their rage toward others, rather than toward themselves (according to Bourdieu’s theory in The Male Domination). They become involved with the legal system, rather than the mental health system. 25 % of patients with antisocial personality disorder also fulfill the criteria for BPD. Looking for this fact, Gunderson and Zanarini write: “Sex bias probably prejudices clinicians to overlook the antisocial features of female patients and the dependent, needy (borderline) features of male patients” [26], but other authors disagree with this argument, reporting that antisocial personality disorder does not include the fluctuating emotions described in BPD, and consider that the male equivalent of borderlines may be as close to narcissistic as to antisocial personality disorders [25].
It is important to draw attention to the fact that a high proportion of people who receive the diagnosis of borderline are said to be gay, lesbian, transsexual, transgender, etc. The question is whether these people express similar kinds of identity “disturbances” that are said to be characteristic of the borderline patient; or whether this pattern is an outcome of clinicians perceiving and labeling. Some men may escape the label of borderline because most of their expressions of borderline-like behaviors are viewed as appropriate to the masculine gender role, so there are no signs of pathology. Some papers found that men in the general population reported more borderline characteristics than normal women. “It is interesting to speculate that clinicians may consider these characteristics as more congruent with male sex roles and may find them more tolerable in men. Conversely, in women these traits may be seen as less appropriate to sex role, and therefore women may be more likely to be labeled as having borderline personality disorder” [27]. Men who are diagnosed as borderline are those who deviate from the masculine gender stereotype [15].
31.2 Gender and Madness: A Historical View
Tracing the history of the modern concept of madness back to the pre-modern discourse of witchcraft, some authors describe how this discourse positioned as “witch” and “outsider” the woman whose deviant behavior threatened social norms [14, 28]. A woman positioned in this way could be punished for her deviancy, and the threat that she posed to social norms could be controlled and neutralized. In the movement from this pre-modern, religious world view to the current scientific (rational paradigm of modernism), Foucault described the emergence of a scientifically determined and controlled concept of insanity [29]. This reflects the change from “witchcraft” as the primary discourse applied to women’s deviancy, to the appearance of the concept of “hysteria” in the nineteenth century. Hysteria became the signifier par excellence that positioned women as pathological and irrational in the last two centuries.
In her historical study of women and madness Elaine Showalter has shown the symbolic association of madness with femininity in the history of Western society, which the author attributes to “a cultural tradition that represents woman as madness and that uses images of the female body…to stand for irrationality in general” [30]. The neurologist Mitchell described the hysteria like “the nosological limbo of all unnamed female maladies. It was also called mysteria” [31].
Showalter argued that hysteria is not, therefore, an individual pathology, hysteria was a response to powerlessness arising from a contradictory expectation about feminine behavior. Chesler coined the term “double bind” to describe the processes by which women can be pathologized both for conforming to, and for failing to conform to, expectations of feminine passivity [32]. Women labeled “hysterical” were, on the one hand, unable to meet social norms and on the other, unable to release themselves from the force of these norms, since the norms had been internalized. Hysteria undermined the norm of female refinement in two ways: directly, through the “fits” or unseemly emotional outbursts to which hysterical individuals were prone, and second, through debilitating physical symptoms that rendered the individual helpless, in a caricature of feminine delicacy [33].
“The more women became hysterical, the more doctors became punitive toward the disease; and at the same time, they began to see the disease everywhere…until they were diagnosing every independent act by a woman as ‘hysterical’” [30]. Hysteria became an epidemic, with women accepting their “illness” and at the same time “finding a way to rebel against an intolerable social role” [14]. “Sickness became not only a way of life but also a means of rebellion, and ‘medical treatment,’ which had always had strong overtones of coercion, revealed itself as frankly and brutally repressive” [30].
There has been an increasing recognition that the label “borderline” may function in the same way that “hysteria” did in the late nineteenth and early twentieth century as a label for women. According to Jimenez, “the similarities between the diagnoses of BPD and hysteria are striking. Both diagnoses delimit appropriate behavior for women and many of the criteria are stereotypically feminine” [34]. Several authors have made reference to this association [14]. “Borderline disorder is a more aggressive version of hysteria, the distinction is the inclusion of anger and other ‘aggressive’ characteristics in BPD, such shoplifting, reckless driving and substance abuse. ‘If the hysteric was a damaged woman, the borderline woman is a dangerous one’” [34]. According to a social construction model, BPD (like witchcraft and hysteria) is constructed as a deviation, in this case from the concepts of rationality and individuality [35].
The gendered consequences of the psychiatric preoccupation with “rationality” have been well explored in feminist theory: women are “typically situated on the side of irrationality, silence, nature and body, while men are situated on the side of reason, discourse, culture and mind,” says Showalter [30], along the same lines of argument as Bourdieu [24]. The consequences of this approach are evident in the psychiatric response to “borderline symptoms”: the BPD diagnostic depends upon a psychiatrist judging whether emotions are appropriate/healthy with reference to the norm of “rationality.” Both anger and fear of abandonment can be judged to be inappropriate, as opposed to being understandable in the context of a person’s history of being violated or abandoned [35].
In the case of BPD, the diagnoses can be applied to women who fail to live up to their gender role because they express anger and aggression. Jimenez argues that “this successor to hysteria, in depicting the borderline patient as a ‘demanding, aggressive and angry woman,’ and in highlighting as one of its features ‘promiscuity’ in sexuality, is reflective of contemporary moral judgments of normal female behavior” [34]. At the same time, the diagnoses is also given to women who conform “too easily,” by internalizing anger and expressing this through self-focused behavior such as self-injury [35]. Wirth-Cauchon discusses how “women diagnosed with BPD are representing society’s contradictions about femininity, with the double-bind of being denigrated for both emotionality and rationality, for active sexuality and for passive servicing of men” [15].
These contradictions are also held in the therapeutic space, as we can see for example in Samuels, who writes that the borderline patient can create a fascination because the “‘ecstasy’ of a madness that maintains a grasp on ‘reality’: intense affect, depersonalization; impulsive behavior, sometimes against the self, brief psychotic experiences; disturbed personal relationships, sometimes exceedingly intimate and sometimes distant. This could be the profile of a saint” [36].
31.3 Social Causation of Distress: Trauma
The document Women’s Mental Health: Into the Mainstream Strategic Development of Mental Health Care for Women [39] acknowledges that many women with a diagnosis of BPD have a history of trauma. At least 70 % have been sexually abused as children [40]. Some studies say that 88 % of people diagnosed with BPD had experienced abuse: for 80 % this was childhood abuse; for 70 % this was early sexual abuse [41], this can lead us to think childhood sexual abuse is a powerful example of the social causation of distress with relation to BPD. However, the history of societal responses to childhood sexual abuse is a history of denial and distortion, and we can also find this in psychiatry’s denial of the etiological relevance of abuse, trauma, and oppression for psychological distress [35]. Freud chose to conceal revelations of childhood sexual abuse by women with the diagnosis of hysteria, by presenting them as memories of fantasies, rather than memories of actual experiences [42]. In consequence, the result was that the extent and impact of childhood sexual abuse was silenced for a century, and continues to be.
As a result of this, some authors consider the diagnosis of BPD a powerful new manifestation of this tendency to deny the extent and impact of childhood sexual abuse, neglect or emotional abuse [35]. Some papers describe how the “symptoms” that define BPD can be better understood as adaptive reactions to early relational traumas. They suggest that it is much more helpful to understand people’s behavior as an attempt to ensure “some measure of mastery, control and alliance with others, in the face of trauma, helplessness and inner vulnerability” than as the result of “a disorder of the personality, that is, solely an internal deficit” [43–45].
The symptoms of post-traumatic stress disorder (PTSD) overlap considerably with symptoms of BPD, and focus on unstable emotions, behavior, and relationships [25]. Herman considers that the BPD behaviors are a form of adaptation to trauma, with the most prominent aspect being the “disturbance in identity and relationship.” Borderline is the most prominent psychiatric diagnosis (with somatization disorder and multiple personality disorder) given to people suffering from childhood trauma. The symptoms were attributed in the last century to hysteria. Given the range of responses to trauma, Herman argues that even the category of PTSD is too narrowly defined, focusing on singular events such as combat, disaster and rape, thus missing the more complex picture of prolonged abuse. She proposes a new category to encompass the spectrum of conditions related to trauma: “complex post-traumatic stress disorder” [46]. This author criticized Otto Kernberg because he minimized the importance of sexual abuse to the appearance of some of the symptoms of the borderline disorders. For Herman, the borderline’s relations to other people can often be understood as strategies of adaptation held over from past relations with abusive caretakers:
Why would a child fail to integrate idealized or terrifying images of his/her caretakers? The reason would have to be either constitutional or adaptive. Splitting is adaptive. Children must preserve some sense of connection at any cost, in this case by walling off the image of the abusive figure from the positive one. I think they do so in a state-dependent way, flipping between modes of affection and terror that accurately reflect their environments. They grow up constantly scanning their interpersonal environments to see if they’re safe, reading subtleties of expression, posture, gesture, and so forth, in an almost uncanny way. However, if you ignore the original reason for this behavior, it looks perverse, incomprehensible, and ultimately pathological [25].
For Herman, trauma provides comprehensibility to the symptoms expressed by people diagnosed as borderline. The patient’s instability becomes understood as a response to an external event, rather being rooted in a character or personality disorder. With the label “borderline personality disorder” there is a risk of losing narrative comprehensibility, placing the patient’s symptoms within a scientific–medical framework of character pathology.
Yet, while sexual and physical abuse are major factors, they do not fully account for the predominance of women diagnosed as borderline, since not all borderline individuals have histories of childhood abuse, and abuse has occurred in 20–40 % of women diagnosed as borderline [14].
Sexual abuse is more prevalent in women than in men. However, the fact that men show a greater reluctance and difficulty to relate these experiences may have an influence on the lower ratio of men, as (in terms of Bourdieu’s habitus) they would not “live up to what society has imposed on them as men,” but quite the opposite, they would be the “dominated” within the “masculine dominance,” needless to say, if the authorship of such abuse belonged to women.
31.4 People on the Borders
Western representational systems stand in a precarious and unstable place in relation to the humanist ideal of a generic, neutral, universal “subject” [47]. Some authors consider than women are represented as “other” to this ideal of the universal subject.
Lévi-Strauss showed that in cultures built on gift exchange, women (and other valuable gifts as food, words, names, tools, powers, etc.) [48] are the most precious gifts within the basic exchange in marriage. The exchange takes place between kin groups. For Lévi-Strauss women become central as an exchange to the foundation of culture. A woman in this exchange assumes the status of gift, object, and not that of a subject who exchanges. Thus, women are located in the interstices of social exchange, serving as the medium of exchange between subjects. The position of a woman functions as (according to Butler) “a relational term between groups of men; she does not have an identity, she reflects masculine identity precisely through being the site of its absence” [21].
This ambiguous position is a “stress point” in the cultural logic, a place where meaning is mobile and shifting, thus revealing the instability of the cultural order. Jane Gallop comments on this dual status of women as both subject and object [49]. According to Bourdieu, who describes the hierarchical relation through the oppositional binarism (outside/inside; public/private; objective/subjective; culture/nature; political/emotional; etc.) [24] the identity is defined through difference.
Susan Bordo analyzes Descartes’ stance, in which the senses of the body are ignored in favor of pure objective reason, resulting in the Cartesian experience of the self as inwardness (“I think, therefore I am”) and the sense of distance from the “not-I” [50]. Women become apprehended as part of the denied separate world, “she is the ‘Other’,” in de Beauvoir’s words [22], but for Irigaray the female sex is not a “lack” or an “other” that immanently and negatively defines the subject in its masculinity. On the contrary, the female sex eludes the very requirements of representation, for she is neither “other” nor the “lack” [21], the feminine is not a negatively defined derivative or opposite of masculinity, but another version of the same masculine image. Women are defined as the derivative of the subject.
Kristeva developed the concept of the “abject” to denominate that which is excluded from the body in order to demarcate it as a bounded and homogeneous entity. Butler describes the “abject” as “that which has been expelled from the body, as excrement, literally rendered ‘Other.’ The construction of the ‘not-me’ as the abject establishes the boundaries of the body which are also the first contours of the subject” [21]. Butler applies the concept of “abjection” to bring to the foreground society’s exclusion of certain social identities in order to maintain the illusion of the dominant boundaries and coherence, self-identical subject [51], “‘it is at once setting of a boundary, and also the repeated inculcation of a norm’; and such instances of social boundary marking ‘contribute to that field of discourse and power that orchestrates, delimits and sustains that which qualifies as ‘the human’” [21].
Grosz argues that “the Abject’s location is in the borderline between inner and outer, self and not-self, that is threatening, because it remains irreducible to either subject/object, or inside/outside. The abject necessarily partakes of both polarized terms but cannot be clearly identified with either. The borderline states, functions and positions are considered as danger, sites of possible pollution or contamination. That which is marginal is always located as a site of danger and vulnerability” [52].
31.5 The Description of BPD
“Do I contradict myself? Very well, then I contradict myself, I am large, I contain multitudes.”—Walt Whitman
BPD is said to be defined by instability: “it not only causes instability, but also symbolizes it” [25], instability in mood, self-image, relationships, and feeling of emptiness or rage.
One diagnostic criterion for BPD pertains to a disturbance in “identity.” Indeed, some authors have argued that identity disturbance, along with unstable relationships, are at the core of “borderline pathology” [53].
In DSM-III, identity disturbance was operationalized as an “uncertainty about several issues such as self-image, gender identity, long-term goals or career choice, friendship patterns, values, and loyalties.” In DSM-III-R, it was described as an “uncertainty about at least two of the following: self-image, sexual orientation, long-term goals or career choice, type of friends desired, [or] preferred values.” In the DSM-IV TR, it was simply characterized as a “markedly and persistently unstable self-image or sense of self.” In the DSM-5 it is characterized by a markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress [6].
31.5.1 Fragmented Selves
Showalter says that the conception of a female subjectivity split between outward appearance of the body as an object and inner subjecthood is important in the analysis of borderline narratives [30]. She interprets this split as an exaggeration of women’s “normal” state, citing the art historian John Berger, who maintains that a woman’s psyche is divided in two by virtue of her need to be simultaneously both actor and observer. He says of the woman:
She is almost continually accompanied by her own image of herself. Whilst she is walking across a room or whilst she is weeping at the death of her father, she can scarcely avoid watching herself walking or weeping. From earliest childhood she has been taught and persuaded to survey herself continually. And so she comes to consider the surveyor and the surveyed within her as the two constituent yet always distinct elements of her identity as a woman [54].
Wirth-Cauchon refers to how Showalter sees poet Sylvia Plath’s autobiographical fiction The Bell Jar as expressing in complex ways these conflicts and splits, and notes that the heroine in the novel, Esther, is “split between the feminine and creative selves.” Esther believes that “motherhood and writing are incompatible. Esther’s sense of an absolute division between her creativity and her femininity is the basis of her schizophrenia.” “The analysis of madness as an exaggeration of the cultural double binds of feminine identity to analyze the fragmented self depicted in the borderline narratives” [15].
In accordance with this author (Wirth-Cauchon) we will use the same classification/description for these fragmented selves.
31.5.1.1 Mask Self
The themes of artificiality and superficiality frequently appear in the borderline case narratives. The patient expresses feelings of artificiality or falsity often accompanied by sensations of emptiness and numbness. “This is described as a superficial, surface mask or person that is a kind of empty adaptation to the surroundings” [15].
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