Borderline Personality: Survivors of Abuse

by David Gersten, MD

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Introduction
This is the first in a series of two discussion on the origins and treatments of borderline personality disorders (BPD). 

If there is a hell on earth, other than war, adult survivors of severe child abuse and/or neglect live there. Those who are close to them are often confused, frightened, frustrated, and angry. Because child abuse and neglect go hand-in-hand, and because they cause the same wounds and the same pain, in this article I will use the term "child abuse" with the understanding that I am always referring to both abuse and neglect. Abuse can be either physical (including sexual) or psychological. At the extreme, survivors of abuse can develop BPD. Our psychiatric hospitals are filled with people suffering from BPD. But there are many walking wounded, high functioning people, survivors of abuse, whose wounds don't show on the outside, but who carry the same pain and suffering as those formally diagnosed with BPD.


Wounds that don't heal

All survivors of abuse must deal with the same four core persisting inner states:  

the "wounded inner child"

the "battlefield" 

the "void"  

the "inner abuser"

In the abuse survivor with BPD, these core inner states can manifest as severe depression with suicide attempts, addictions, violence and even psychosis. Everyone reading this article knows someone who is a survivor of severe child abuse... or you may be that person.   

Let's begin with highlights of the diagnostic criteria for BPD, according to DSM- IV (Diagnostic and Statistical Manual).

"A pervasive pattern of instability of interpersonal relationships, self-image, and affects (moods), and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships, 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, threats, or self-mutilating behavior.

6. Mood instability such as intense episodic dysphoria, irritability or anxiety, usually lasting a few hours.

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger.

9. Transient, stress-related paranoia." 

These nine basic criteria should give you a basic idea of BPD. 


Problems with conventional approaches to BPD

I am further clarifying BPD for several reasons:

1. At least half of the patients in psychiatric hospitals suffer from BPD.

2. People with BPD can be highly functional, unlike the vast majority of people with schizophrenia. 3. People can suffer with degrees of BPD. Everyone with BPD comes from a background of abuse, but not everyone who grew up with abuse develops BPD. As I mentioned above, everyone who grew up with abuse carries four persisting inner states, of which the "void" and the "inner abuser" wreak the most havoc. 4. People who have been abused, whether BPD or not, can be cured, but the process takes decades of intense inner work, psychotherapy and spiritual work. 5. In this unstable society of ours, abuse is common. Therefore, we are all suffering with the long-term effects of abuse or we know someone who is.

Over the last fifteen years, most people with BPD have been given other diagnoses. They can be very anxious and be labeled with "Panic Disorder," or depressed and labeled with "Major Depression." Because their moods and behaviors can slide in so many directions, they are often misdiagnosed as Bipolar. The differences in diagnosis are huge as are the treatments. If you are diagnosed as Bipolar (manic-depressive), psychiatry has an arsenal of medications to give you, including anti-depressants (like Paxil), anti-psychotics (like Zyprexa), and mood stabilizers (like Lithium). The sad truth is that medications almost never work in BPD. Or if they do work, it is hit and miss.

You need to understand something about the inner dynamics of a borderline or abused person to understand what drugs do and don't do. Within each survivor of abuse is a giant abyss, the "void," metaphorically as wide as the Grand Canyon and a bottomless pit. What impact would there be on the Grand Canyon if you tossed some Lithium, Paxil, or Zyprexa into it? None. The void swallows up medication and the individual has only temporary, if any, relief. If a person with BPD has been treated for five or ten years, he or she has often been treated with dozens of different medications.


The inner worlds of the abused person

Because BPD and abuse are so important, this article will be in two parts, with this first part focusing more on a description of the problem and the next article focusing on treatment. I do not mean to inspire fear and doubt by sharing my experience about the relative lack of benefit that medications provide. I want to emphasize the point that many of these people can be immensely aided, and can be totally cured rather than anesthetized with medications. It does, however, take decades of immense motivation and patience on the part of the abuse survivor.  

As an example of BPD, I will share the history of a woman, now in her fifties, who has spent her life battling the demons of abuse. I'll call her Marissa. The history that follows is a composite of several people. I worked intensively with people with BPD for eighteen years, both in an in-patient and out-patient setting. I no longer work in psychiatric hospitals, but I do work in an office setting with survivors of abuse who have a passion for truth, and a hunger for recovery that cannot be quenched. I worked with Marissa for several years, through 1997.  

As a child, Marissa was the victim of mental, physical, and sexual abuse. Her father, an alcoholic, began sexually molesting her when she was eight and continued for six years. An older brother also molested her. Her father was violent when drunk, would beat her for the slightest "error" on her part, the slightest deviation from perfection. Her mother was cold and aloof. She knew about the abuse, did nothing about it, denied that it ever happened, and insisted on keeping the family secret unspoken. Marissa was only able to press forthe truth much later, when she was 40 years old.  

At age 17, she ran away from home, and retreated into the woods for 20 years, living in deserted cabins, walking miles a day to fetch water from the river, living off the land. Her mountain friends were also refugees from society. At last, she had some peace of mind.

When she moved back to the city, she couldn't cope very well. She fell apart emotionally and sometimes would go through 20 different moods in one day Ñ from elation to suicidal depression Ñ from rage to serenity. She went from one chaotic relationship to another, often ending up with men who beat her. She could not stop herself from engaging in relationships that repeated the abuse with which she had grown up. She attempted to kill herself many times. Yet Marissa is immensely gifted, a talented singer, painter and yoga instructor, and has held many jobs. She is also tremendously intuitive.

Marissa gets so overwhelmed by her emotions that she is regularly "acting-out," constantly engaging in behaviors that temporarily relieve her anguish but undermine her safety and security. She comforts herself with alcohol, speed or men. She can never seem to get the basics of her life sorted out. Her emotions, finances, housing, food and relationships are always in a state of flux.

The first impression one has of a borderline personality may be that they are very depressed. A common mistake in psychiatry is to treat this depression with anti-depressant medication, which rarely works for BPD. An important question to ask is, "How long have you been depressed?" Borderlines usually say they've been depressed their entire life. In other words, their depression is not something they can compare to a time or a feeling of happiness. Depression is not a change for them. It is their baseline state of being.

Marissa's inner world is filled with all shades of emotion. She feels torn to pieces inside, as if she is always standing at the edge of a great void and terrified of falling into the it. She has many unpleasant mood states that simply don't have words or names... so patient and doctor begin to call all of that intense emotion "depression" or "bipolar" for convenience's sake.

Borderlines can appear quite normal and often can function normally. They may have terrifying episodes of depression, despair, suicide attempts or psychosis, but when they are well, they may be able to feel well, look well and perform adequately both in the working world and in relationships. They may sustain long-term relationships, but there is almost always a lot of chaos in those relationships.

These people have "sliding states of consciousness." They readily go in and out of different mental states and different states of consciousness. They can be depressed in the morning and elated in the evening. They can attempt suicide the next day. Borderlines can "slide" in many directions. They may slide into a state of psychosis that is similar to schizophrenia... and they may slide into the "spectrum of mood" and develop something that looks like mania. Or they can develop what looks like a panic disorder. There simply is no foundation to their personality, so they live as if they are in quicksand, constantly struggling to get out, and constantly being dragged back into the mud.

Borderlines are the real "split personalities." They are fire and ice; Jekyll and Hyde. When they are good, they are very very good and when they are bad, they are horrid. The source of their problem originates in childhood. Their parents did not love and accept them unconditionally, through good times and bad.

When Marissa was angry as a child, her parents despised her, so she "disowned" her anger. She didn't receive a healthy message, "I love you even when you're angry."

Because people with BPD learned as children that the expression of anger was dangerous, they split the anger apart from the rest of themselves, tuck it into some corner of their mind until it breaks loose decades later. Their good side has no "bad" in it. As a result, romantic partners of borderlines can be totally confused because, "When she is good, she is just the best I've ever known." These people are devastated when their borderline partner switches into anger or their "bad" side.

Borderlines can be very psychic and can experience a wide range of super-normal states. Why is this? They have "permeable" ego boundaries. They don't seem to know where "they" stop and "other" people begin. So they are often "open to the universe" and receive information easily. Many of my borderline patients have had psychic experiences while I was with them, knowing the phone was about to ring or having a precognitive dream. They may have experiences of divine light into which they blissfully merge. The downside to their openness, however, is that they are also terribly open to their own unconscious minds and can't seem to stop the flood from the unconscious that can pour over them.

When Marissa told me that she saw auras around me and around many people, I believed her. And when she told me that for two years as a mountain woman she was frequently in a state of samadhi or nirvana, I believed her.

Marissa's inner battlefield is projected out into the world. For her there are "good guys" and "bad guys."

A borderline will idealize one person and denigrate the next. The Marissas of the world can drive their psychiatrist and everybody else crazy in a hurry.

She is not just living with emotional turmoil. Marissa is physically exhausted, suffering from chronic fatigue syndrome and fibromyalgia. She can't always concentrate or think straight. Her immune system is shot. Her muscles ache. She has intestinal problems and runs a low-grade fever.

Marissa may sound as if she has little in common with the average person, but we can empathize with her better if we realize that the core of her problem is a lack of deep trust in herself and in others. Almost all of us know what it feels like to be betrayed by someone we love. A powerful emotional bond is severed, and may never be reparable. The borderline first experienced such a dramatic rupture in trust as a small child. Continued episodes of abuse deepened the lack of trust until a "void" became a permanent internal state.


Psychodynamics of BPD

Let's look deeper at the trauma that creates BPD, and the stages one goes through when abused. As a child, abuse tears or rips the mind-body fabric and shatters a sense of wholeness. Body, mind, and spirit are all split apart. Unconditional parental love is the glue that keeps us whole as children and allows us to remain intact when we are angry or difficult. Lack of love tears the mind-body apart, but the child learns to fake it so she can look normal. Inside, that child does not always feel like a good person, for good and bad become split apart, and then the personality splits apart.  

The concept of "splitting" was first elaborated on by Dr. Otto Kernberg. In order to help manage inner turmoil, the person with BPD projects "good" and "bad" onto important people in their world. For example, one person at work may be seen as all good and another as all bad. The projection of all good onto one person is called "primitive idealization," and the projection of bad is called "projective identification." This splitting becomes an externalization of the inner conflicts of the person with BPD.  

In a psychiatric hospital, here is how such splitting may play out. The borderline patient may treat the p.m. nursing staff as "angels," and, in turn, the p.m. staff will adore this patient. The a.m. nursing staff may be seen by this patient as horrible, depriving, and uncaring people who should leave the field of nursing. The unconscious "set-up" is so well executed that a.m. and p.m. nursing staff begin getting in serious arguments with each other, and may vehemently disagree about what the patient needs. Unless, someone recognizes that the process of splitting is going on, a.m. and p.m. nursing staff can become quite distanced from one anotherÉ all because of one patient. Once the doctor recognizes what is going on, and explains it to both a.m. and p.m. nursing staffs, tension in the staff disappears and doctor and nurses can begin acting in a unified fashion.  

Once the split is identified, and the "good" and "bad" people refuse to buy into these roles, the responsibility for dealing with painful emotion returns to the person with BPD. In a non-psychiatric setting, in everyday life, those who are being put on high pedestals by a loved one with BPD, who is being overly praised and idealized, must watch out for the fall. For the idealized person will usually be "dethroned" or knocked off his or her pedestal, ultimately becoming the villain in the eyes of the borderline. In other words, in order for the borderline to maintain her unstable instability, she will juggle the people in her world, sometimes seeing them as heroes and sometimes as villains.  

All of this external activity is a manifestation of the split, and is an attempt to avoid feeling the terrible pain that will not go away until true healing occurs. This split, this inner "rip" can persist throughout life. It creates a low-grade depression, and after twenty to thirty years, the immune system can crack under the pressure of depression and a fragmented mind-body. It is at this point that many survivors of abuse come down with chronic illnesses, such as chronic fatigue syndrome. It is not that CFS is a "mental" illness. Rather, about 20 percent of those with CFS are survivors of abuse, their immune system being set up for a fall when they were small children.  

Not only do parts of the mind separate, but mind-body integrity is challenged.


Spiritual aspects of BPD

There is also a metaphysical aspect of abuse. Many children in the midst of severe abuse leave their bodies. They watch the abuse from a distance, perhaps from the ceiling, while their body is tormented. I believe that these out-of-body experiences that are so common in BPD and survivors of abuse are the trigger for their enhanced psychic abilities. Once you have mastered the art of leaving your body, you quickly gain access to psychic abilities and even the ability to heal. It is a tough way to attain these gifts, but these gifts of the borderline do need to be acknowledged as genuine, rare gifts, and not just part of the problem.  

While the borderline can attain siddhi powers, such as precognition, ESP, clairvoyance or the ability to perform hands on healing, she often becomes alienated from God as a child. The reason is quite simple. During terrible abuse, many children silently call out to God for help. They call and call but feel that they are unheard or ignored, or worse, that the abuse is accepted by God. They are furious with God. Then they feel abandoned by God. Finally, they may decide that God does not exist. As a result, their spirit becomes part of the split. To put it another way, while spirit is always part of us, the very core of our being, the abused person may lose all awareness of spirit or God, unconsciously creating blockades that prevent the "light of spirit" from shining through the rest of their being. Powerful beliefs develop that support the notion that God and spirit do not exist, and these beliefs deepen the void, and prevent total integration of the individual as body, mind, and spirit. Body, mind, and spirit are all separate, although inhabiting the same space.  

As you can imagine, treatment of borderlines is difficult and takes a long time. "Good" and "bad" emotions must be re-integrated into one personality. The tear in the mind-body fabric needs to be healed. And finally, spiritual alienation must be healed. Is this not the essence of all healing?  

(Part 2 on the Borderline Personality)  


David Gersten, MD (formerly Dennis Gersten, MD) practices nutritional medicine and psychiatry and can be reached at his Encinitas office 760-633-3063. Please feel free to sign up for Dr. G's Health Digest newsletter at http://www.aminoacidpower.com/ and access 1,000 on-line pages about holistic health, amino acids and nutritional therapy. 

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