The Concept of Personality Disorders in General and Borderline Personality Disorder
Personality disorder, as a term, may sound negative and judgmental and it is important to have a clear understanding with our patients of the meaning of the term. We explain that there is a group of disorders in the DSM-IV, ten of them to be specific (a number that will be reduced to six in the DSM-V), that are thought to be long-term and enduring, in contrast to episodic, personality styles that at their core are defined by difficulties in the person's subjective, internal sense of identity, and chronic difficulties in his or her interpersonal relationships. It is noteworthy that the DSM-V description of personality disorders includes this emphasis on sense of self and relations with others more than the previous editions of the DSM did.
We explain that the ten different styles have many overlapping features and that most people have a mixture of those styles, but most importantly, that when people personify and live out any of those styles with a certain consistency, inflexibility, and in such a way that causes a certain level of distress in one's emotional and interpersonal life, they meet criteria for a personality disorder. For patients with BPD, in reviewing the DSM-IV symptoms that the particular patient in question meets, we note that there are different sub-types of BPD patients, each with different sets of primary or most-problematic features. Some may be more impulsive and overtly inappropriately angry, whereas others may be more "under the radar," characterized more prominently by the sense of emptiness, fears of abandonment, suicidal feelings, and more subtle shifts in their experience of others, from idealizing others to more quietly feeling devaluing or contemptuous of them. So with each patient we explain our understanding of his or her BPD symptoms. We also find it helpful to give an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and rapidly shifting; 2) relationships tend to be conflicted and stormy; 3) there may be impulsive, self-destructive or self-defeating behaviors; and 4) there is a lack of a clear and coherent sense of identity (this last problem may underlie all the preceding ones).
Our view is that the problems in the patient's identity, that interact with a propensity to intense emotional responses and lead to the associated difficulties in the patient's interpersonal life and the other symptoms of BPD, are best explained by a "divided" or "split" sense of self and others. We refer to this as the "split psychological structure" in which different, contradictory ways of thinking about the self and others manifest themselves at different times, or in different ways, but rarely if ever, at the same time. For example, a patient may present as morally rigid, highly concerned about proper and respectful behavior, but at other times engage in questionable moral practices and behave in provocative and inappropriate ways. Or a patient may present as very quiet and meek, describing a history of poor treatment by others but may, at times, demonstrate hostile and contemptuous behavior toward others. Yet another patient may present as self-sufficient, arrogant, a "know-it-all", rejecting all that the therapist has to offer, whereas the therapist knows from the history and referral source that the patient has recently suffered fleeting depressive and suicidal feelings pursuant to one in a string of occupational failures. None of these "self representations" are specifically listed as BPD criteria in the DSM. Nevertheless, they each can be viewed as part of a dyad – a specific internal mental representation of self in relation to another. A borderline patient's particular set of mental dyads involves contradictory representations of self, each of which experienced as true and authentic parts at the time it is being experienced. This alternation across time between different experiences of self can lead to confusion, anxiety, depression, and a sense of emptiness that comes from not having a stable sense of the core self.
How does this "split" sense of identity emerge, and why? We understand personality a person's habitual way of experiencing self and others and of interacting with the world around him. We see these habitual patterns of experiencing the self and others as built up from people's prior experiences, particularly those emotionally-charged interactions between the infant/child and significant caregivers, which are repeated over time. These experiences of self-in-relation-to-others from early in life are part of the normal developmental process and result in a set of expectancies as to how the self will be treated or experienced by another, and vice-versa, in subsequent relationships. In early infant development, specific experiences lead to dyads are associated with specific emotions – pleasure/satisfaction and pain/frustration. In early life, these dyads are not accurate or literal representations of what is actually happening; rather, they tend to represent polarized, extreme images and affects which are affected by the individual's particular temperament – intense or quiescent, which links this way of thinking about BPD to current neurobiological studies.
In the case of healthy psychological development, these early, extreme and disconnected representations gradually become integrated into more complex, subtle and realistic internal images of self and others. We come to realize that we, and others, have both good qualities and bad, that we can experience disappointments in ourselves or others while still appreciating the good qualities. We learn that experiencing negative emotions does not destroy the capacity for positive emotions and that our emotional state can be complex, with a variety of emotions of multiple valence (rather than only all positive or all negative) in relation to others. In the case of healthy identity, various representations or ways of experiencing the self can co-exist without a sense of tension, dissonance, or threat. One can see oneself in any given interaction as smart, yet with something still to learn; one can see oneself as driven, a bit aggressive, yet at the same time patient and forgiving; one can see oneself as one who is dependent upon others, but is capable of operating in various spheres, effectively, on one's own.
Indeed, healthy identity is defined as integrated and coherent, stable across time, and as based on a realistic self assessment in which positive affects predominate over negative affects, and with resulting ego strength that is sufficient to navigate life's challenges and disappointments. In the case of the personality disorders, and BPD in particular, however, there is a failure of integration of these self representations. Internalized dyads associated with sharply different affects (positive and negative) remain split off and continue to exist independently from one another so that the world is experienced in highly concrete/all-or-nothing terms, and with confusion and lack of continuity. Consequently, in response to triggers (life events), an individual experiences himself, and others, in terms of extreme and simplistic representations that are not coherently connected with the representations of self and other that might be triggered by a minor event (e.g., the individual may feel very happy and valued when a friend smiles at him, and may feel sad and worthless if the friend is late for meeting; the corresponding images of the friend would be a loving person in the first instance and a rejecting person in the second.)
Let us now extend this idea of the split sense of self, this sense of a dyad that is split, with part of the self being experienced at one time and another part at a second point in time, to the realm of interpersonal relationships. For the BPD patient, at each point in time he is experiencing only one self-representation, connected to one dyad; for example, the rigidly moralistic self at one moment, or the victimized self at another moment, or the nurtured self at a third moment. We find that each of these partial self-representations corresponds, at that moment, to a view of the other, who is experienced in the moment as the embodiment of the other side of the dyad. When a BPD patient is experiencing himself as moralistic, he tends to experience others as loose, slackers, unrighteous. Similarly, the patient experiencing herself as a meek, innocent victim tends to experience others as hostile, hurtful, and persecutory. The BPD individual who is experiences herself as nurtured and cared tends to experience the other as the perfect provider and caretaker. As life develops the situation is complicated by the fact that the patient may have populated his or her life with characters who actually, or at times, embody some of those tendencies. It is therefore very important, in the course of therapy, to sort out the degree to which the patient's description of others is colored by the representations in his or her mind in contrast to the degree to which the patient is accurately describing others. This is one reason we find it very useful in therapy to focus on the transference – the patient's perception of the relation with the therapist – so that we can compare the patient's experience of what is happening with what appears to be happening on an objective level. As we get to know patients, what we tend to find is that patients need to experience others, including often their therapist, as embodying the opposite of side of the dyad. In sum, the patient's experience of others is as divided, split, and unrealistic as is his or her sense of self.
The other BPD criteria tend to follow from this description of splits in the representation of self and other. When a person lives life with a need to avoid certain experiences of the self, positive or negative – loving or hating, because that self representation is too threatening (or perhaps too exciting), it results in a feeling of instability, of incompleteness, as the experience of the self shifts across situations and different interpersonal situations. Indeed, patients with BPD describe a subjective sense of instability, emptiness, and inner confusion. Other people then, come to play an important, albeit unrealistic role in the BPD patient's life. They are not simply friends with whom to experience and share life, but crucial assistants in the patient's self regulation (although usually unaware that they have been placed in this role). For example, if a patient needs to experience himself as smart or popular, and chooses associates that help mirror that feeling, then he needs to carefully control interactions: he can't have others look smarter or more attractive than he is, because then his sense of inadequacy would come into awareness. Similarly, a patient can't have the other leave him because then he's on his own, to face his worst sense of self. In another example, if a patient can't tolerate her own tendencies to be judgmental, contemptuous, and hostile, it stands to reason that she will often see in others those same tendencies, and will experience others as judging her, as being unreasonably cruel or angry with her, and at times may accuse them as such.
Although these processes do not operate consciously in the individuals with personality disorders, one can easily imagine the strains that this way of experiencing the self and the world places on one's interpersonal relationships, and one can also see how some of the other BPD criteria would logically follow, namely the intense and unstable interpersonal relationships, the propensity towards intense, inappropriate anger, the fears of abandonment, and, one can imagine, the impulsivity, the transient suicidal feelings and parasuicidal behaviors that result when others fail to assume the roles the borderline patient has unconsciously assigned them, or when others actually reject or leave the patient, with a mix of confused, exasperated, angry, and/or frustrated feelings.
This understanding of borderline and other personality disorder has led to the development of Transference-Focused Psychotherapy, which is described in a separate section of this website.
By Barry Stern, PhD
Frank Yeomans, MD, PhD
For private referrals—Dr. Frank Yeomans at 212-213-3677.
At the current time, we are focusing on providing services to people in the metropolitan New York area. We have colleagues in some other geographical areas, but unfortunately are not able to provide referrals for all areas.