Help! I Can’t Hear Myself Think! Or Myself! Or Myself! (Or, Opening New Possibilties for the Borderline Mind)
On occasion, everyone finds that emotions have bested them. The person we have a crush on doesn’t call us back for two days, and suddenly the world feels just a bit less bright. We do poorly on a test, and though we recognize that in the scheme of things it’s not a big deal, we can’t help but imagine that our future has been ruined. And then, another piece of ourselves works to quell the fire: the moment passes, the crush calls (or doesn’t), we watch a TV show or two, we get a good grade on the next test (or we don’t), we call a supportive friend and talk briefly, and life goes on. But for some people, regulation is not as simple, and keeping things “in perspective” is a lifelong battle fought and often never won. A sideways glance from a friend is suddenly impetus for a raging fight, a night of cutting, an alcohol and drug-filled binge, a suicide attempt.
I would end up in the ER. I would have my stomach pumped and then Iwould be either sent to a psych unit or I'd be sent home or I wouldescape, you know? There was a lot of drama in, you know, being takenout of my apartment in handcuffs while bleeding, going to an ER under,you know, police escort. I would continually up the ante. I wasn't satisfied with how people reacted to me because I overdosed on 200pills. Then the next time I would try 400 pills. It just felt likean overwhelming need to somehow punish myself, annihilate myself, destroy myself. It was my one purpose in life, to destroy myself. I--I--I can't even explain that--there was no rational reason for it but the sense of emptiness and loneliness was very hard to tolerate.
Often, people for whom regulatory problems are the hardest end up diagnosed with borderline personality disorder. Borderline patients are consistently some of the most reviled in the mental health system. They make up an estimated 20% of the population in United States’ residential psychiatric facilities, and have a prevalence rate of about .7-2% of the population (2). They are prone to dramatic actions both in and out of therapy, considered emotionally manipulative, and extremely unresponsive to most treatments. Still, like with so many diagnoses, one borderline patient looks very different from another. Some, like Kathleen, may end up losing their jobs, their husbands, their wives, or their homes. They may spend years shuffling in and out of hospitals and psychiatric facilities, drug rehabilitation clinics and jails. They may abuse their spouses or their children; they may cut themselves, burn themselves, or change their appearance every week. Some may simply complain of feeling empty inside. They may perform well in school, work at high powered jobs, but completely fall apart every time they break up with a girlfriend or boyfriend. They may smile all the time, but when asked, tell you they feel nothing, they have always felt nothing. They will always feel nothing. They may kill themselves (and approximately ten percent of those diagnosed will), they may attempt suicide a few times a year for years, or they may threaten it every time you say you’re going to hang up the phone (2). So what is the common thread that ties these people together under one diagnostic rubric?
BPD is characterized by the psychiatric community as “instability in moods, interpersonal relationships, self-image, and behavior,” though the criteria according to the DSM-IV are more specific (3). In order to receive the diagnosis a person must exhibit five or more behaviors and symptoms from a list of nine, which can be broadly defined by five specific areas of faulty cognition including emotion regulation, trouble controlling mood-related behaviors, inner personal and interpersonal relational problems, inability to establish an idea of self, and periods of disassociation (1). When BPD was first named in the 1930’s it was thought to be a diagnosis of patients on the literal borderline between psychosis and neurosis (4). While some who receive this diagnosis may exhibit the most extreme of the behaviors – periods of disassociation in which they feel as if they are floating outside of their body, separate and apart from their physical selves, even occasional psychotic episodes – some will never present with these “on the cusp” symptoms.
What seems underlie the idea of a “borderline personality” is an individual who believes he or she does not have much of a personality at all. Whether this lability figures into feelings, behaviors, or both varies from person to person. But there is a unifying feeling of emptiness, a complaint that inside “there is no there there.” Almost all will say that life invalidates them constantly, that people around them invalidate them, and that this has always been so.
So they have a sense of not--either not knowing who they are, of changing what they want to do on a daily basis--not being able to make decisions, or mo--almost everyone if you--if I said to you, `Experience yourself right now.' If I said that, most people experience something. And a person of these criteria for borderline, if you ask that question, they would be very likely to say, `What self?' because they don't have a sense of a self.
And, for years, doctors, psychiatrists and psychologists alike, have basically washed their hands of these patients. They took up too much time, and their problems were impossible to handle. Even as leaps and jumps were made in terms of finding medications that calmed anxiety and depression, mania and fits of psychosis, this pervasive feeling of emptiness eluded treatment.
But thinking about the etiology of BPD is a fascinating thing. How does one grow up without a sense of who you are? Though traumatic childhood events can be contributing factors for BPD symptology (an idea strengthened by some of the similarities and overlaps with post traumatic stress disorder), there is a lot of evidence that genetic tendencies are significant as well. Being separated from parents at very young ages, continuous subjection to abuse during childhood, or simply parenting that doesn’t support or jive with a child’s needs are all environmental factors that often exist in the histories of borderline patients. It is possible that in some cases individuals who exhibit borderline behaviors, even at young ages, are more likely than other people to incorrectly remember events, perhaps even lying about them, to try and manipulate others, and to engage in behaviors, even while very young, that may increase their susceptibility to drastically early sexual experiences (5). Regardless whether it’s cause or effect, some studies indicate that about forty to seventy-one percent of individuals diagnosed as BPD report a history of sexual abuse by a nonpeer during childhood or early adolescence (6, 3). As explained by Dr. Otto Kernberg, one of the leading psychiatrists in the field of BPD, such repeated or elongated severe trauma experienced by an infant or child can lead to the death of cells in specific areas of the brain that encourage and sustain deregulated and harmful behavioral patterns (7).
The genetic component of BPD is another area with commonalities among patients’ stories. There are very clearly biological factors that seem to increase a person’s susceptibility to the disorder, including a tendency towards lack of impulse control and aggression, often caused by various neurotransmitters in the brain, included reduced serotonin activity, and increased acetylcholine activity, which is often associated with affective instability (8). It has been shown in laboratory studies that BPD patients react much more negatively than patients with other personality disorders or other control group volunteers when given physostigmine, a chemical that prevents the breakdown of acetylcholine (9). Recent twin studies suggest that there is a strong familial correlative for BPD, and it is almost certain that a large number of the underlying components of the disorder are linked to inherited susceptibilities. Many of the symptoms that can lead to a BPD diagnosis have been shown to have strong genetic components including social avoidance, cognitive dysregulation, oppositionality and affective lability (8).
A common tale among parents of individuals diagnosed with BPD is of the extreme emotional reactivity of their children, often from infancy. While people under the age of eighteen cannot be diagnosed with BPD, the symptoms are generally believed to have roots in childhood. As young babies, these individuals are frequently reported as having cried often and sometimes inconsolably, getting easily upset and having difficulty modulating their feelings (9). As time passes, this vulnerability to both positive and negative emotions and experiences often increases in volatility. Because of these outsized feelings, parents end up dealing inconsistently with their children, intermittently rewarding and punishing for the same extreme emotional outbursts. A child who cries hysterically when something small happens may initially be comforted, but then quickly told, “Perk up, it’s not a big deal.” Though the parent’s intent may be instructive rather than malicious, the child, already feeling extremely upset, ends up feeling invalidated, too.
Additionally, as more research is done on addiction to things like drugs and food, it seems that people who get the least pleasure from a substance often crave it the most, and are more likely to overuse it (10). The same seems to be true about emotional connections and comfort. The less predisposed a child is to receive pleasure from a parent’s attempts at soothing, the more extreme the need will become. Currently, some researchers have suggested that the genes that control for our susceptibility to pleasure can be influenced by the emotional interaction young infants have based on the touch of their guardians. These touches release opiates that can help calm us down, though a child who has fewer opiates released may feel less soothed. As time passes this child craves the comfort more and more acutely, while the parent or guardian feels more and more frustrated and hopeless when caring for the child, which in turn lessens their ability to soothe (11). In time, BPD patients find themselves both unable to self soothe, and extremely demanding of their emotional support system, consistently expecting others to provide them with comfort in a way that they have profound difficulty deriving from either external or internal stimuli.
In the conception of the bipartite brain, the unconscious “pragmatist” collects sensations, emotions, and pictures of the outside world in a plethora of different ways, and interacts with them accordingly. Meanwhile, the “idealist” in the neocortex, working as the I-Function or “storyteller,” helps organize what goes on below into a coherent narrative, amalgamating the many selves of a person’s tacit mind in order to aid in creating a higher-functioning self who recognizes behavioral patterns and helps to reconcile conflicts among both the “lower module” selves and each other, and between its own perceived needs and desires and those of the selves below (12). There is no single self or set of objectives for any person, or even a dominating self. There is simply our narrating I-Function or “storyteller”, working as a sort of organizational body, at least in a person’s conception of self. All brains are constantly sifting through multiplicities of their tacit pathways, functioning in a way that allows an individual to create a consistent idea of who they are, while also allowing for multiple desires and wants – almost multiple individuals – to function symbiotically within the same body, each expressing its needs at certain times, and each allowing for other, possibly conflicting selves, to do the same on occasion (13).
In the brain of a person with the components that make up BPD, the I-Function is too adamant about gaining control, and finds itself unable to allow for the necessary multiplicity of selves. The biological underpinnings of the disorder, as well as the stressors that can lead to it, may predict just this sort of end result. According to research, it seems likely that the emotions engendered in the tacit mind from external stimuli are often coded into much stronger feelings in some infants than in others (14, 8). Parents whose children connect emotion with more extreme feelings often have difficulty soothing their children, particularly in consistent ways. Though guardians may mean well, parenting a child with such extreme moods can be frustrating and unforgiving, which creates a cycle where the child doesn’t receive soothing that feels helpful or adequate. Additionally, as discussed above, it seems that people who exhibit this “emptiness” may in fact have a more difficult time experiencing soothing generally, making the craving for it more extreme. While the feelings experienced by causal emotions are intensified, the ability to soothe these emotions is decreased. Combined, these two factors can help lead to neural changes that make the “splitting” or “black and white” thinking that occurs in the borderline brain more likely to occur. If a young infant separates its emotional reaction to its mother from its thought processes about her as individuation is occurring, the setup for an idea of “good mother”/”bad mother” may end up creating a different cognitive structuring in the brain than in a baby who doesn’t do this (15). Since the neurons connecting the hemispheres of the brains aren’t fully developed, and since the child does not know language, communication between the different facets of the brain is more difficult. As the brain matures, this child begins to see the world around her in two ways, as she cognitively recognizes the desire of people to help soothe her, but simultaneously experiences a lack of soothing from the world around her. The splitting becomes embedded in the neural functioning of the brain.
This mind construction leads to an individual with a truly difficult time conceiving of his- or her-selves, and an equally hard time modulating between the various needs of different aspects of the mind. A brain that is able to allow for a more assimilated view of both its components and the world is better able to navigate amongst its various wants and motives. Still, though this mind continues to experience maximal feelings in response to emotional stimuli through adulthood, it has great difficulty properly integrating soothing techniques into its repertoire and distinguishing between its hierarchies of desires. This lack of ability to self soothe can be exacerbated by genetic tendencies, by lack of exposure to viable soothing techniques as a child, and also by both childhood trauma and/or simple miscommunication between parents and borderline-prone children.
This is why borderline patients are seen as constantly in flux, without the same linear thread that appears to run through many people’s lives, at least narratively. Though the I-Function is, in fact, too intent on expressing its dominance in the borderline individual, it ends up unable to perform its most basic functions of sifting and storytelling. “Normal people are ambivalent and can experience two contradictory states at one time; [people who exhibit borderline symptoms] shift back and forth, entirely unaware of one feeling state while in the other,” offers Dr. Jerry Kreisman in one of the popular commercial books about BPD (16). One of the differentiating factors between BPD and bipolar disorder is the speed of mood swings in the former, which can be significantly more extreme than even that which people with rapid-cycling bipolar disorder present with, as if there is no unifying structure in the mind able to choose which course to take for a given amount of time. As Dr. Marsha Linehan describes it, “it is the inability to regulate one's self despite one's greatest efforts to do that” (1).
With the I-Function not able to create a cohesive narrative, a person ends up engaging in storytelling techniques that are based on different assumptions than those used by people who are able to integrate multiple selves functioning simultaneously. The brain, overloaded first by feelings, and then by selves, cannot regulate behaviors. And so, an individual resorts to both high risk and self injurious behaviors as acts of self anger, but also because the I-Function is unable to modulate between the input that is saying “I want to do drugs,” or “I hate myself and want to see myself bleed,” or “I want to die,” and the higher order input that might, a few moments later say, “That’s a bad idea,” or “Remember the last time you felt this way, and then it passed?” or “What else can I do to change my current experience?” Additionally, the I-Function is unable to allow both the “affective storm” self and the self who would imagine the perspective of a second individual to coexist and interact, creating some of the borderline behavior that is considered highly manipulative. Since external soothing was never sufficient, more is constantly craved, and so the “affective storm” self needs a solution from someone it is close to, and will work itself into frenzy with any perceived abandonment. The self with the motive to obtain soothing will stop at nothing in order to get it, including threats both idle and literal. For example, a person may threaten suicide in order to get the attention they crave, and then may either go through with the attempt, may end up in a different momentary state before getting around to making the attempt, or may be simply lying in order to get its needs fulfilled. Another self, one who might recognize how awful this behavior is, might only have the opportunity to express itself after the affective storm has already past, after the threats have long been made and perhaps been acted upon.
So of course, it is no surprise how resistant to traditional treatment methods this underlying factor of BPD has been. Often medications and talk therapies have been used to treat comorbid depression and anxiety, mania and addiction, but none have worked adequately for the pervasive emptiness, or the range of accompanying symptoms. Most therapies rely on the participation of the I-Function in conjunction with tacit selves in order to work. Learning to consciously think about one’s selves, or even simply learning skills that can be executed, a patient is able to implement new modalities of thought or behavior between tacit and “storyteller” selves. A new narrative can help influence new behaviors and understandings, and new behaviors and understandings can help influence new narratives. But if your core issue is an inability of selves to exist simultaneously, and you have an I-Function unable to aid in the balancing of selves, therapy encouraging cooperative change is going to be almost impossible to execute. A “self” may strongly want to change, may understand the need to incorporate new behaviors and attitudes into life, and yet may be unable to assert its message when another “self” is holding momentary reign. Until the mind can dialogue, it will never be able to really work on changing behavior or thinking patterns.
And so, nearly impossible to both handle and treat, people diagnosed with BPD have been stigmatized even within the mental health community. As Dr. Joel Dvoskin, former commissioner of the New York State Office of Mental Health put it, "Why would psychiatry and psychology turn so viciously against people they call mentally disordered? Apparently the greatest sin a client can commit is poor response to treatment. What is apparently so wrong about these unfortunate souls is that they have yet to demonstrate the ability to get better in response to our treatment. Thus, they don't make us feel very good. With a few notable exceptions, we have simply given up on helping people who desperately need us to do a better job of helping them," (17). Many doctors and therapists resist BPD sufferers because their prognosis is rotten, and because they engage in the same behaviors with mental health workers as they do in other close relationships. Even when addressing the problem of mental practitioners who blame patients for not getting better, doctors still accept this attitude towards those who are considered borderline, as Dr. Richard Friedman, the author of a recent article encouraging doctors to see past other stigmas, falls prey to. (In the end, a patient who was thought to be presenting with borderline symptomology, who displayed “some serious character pathology” was portrayed positively for actually just being bipolar (18).) Traditionally the consensus has been that BPD patients are impossible to help and impossible to disengage from treatment, essentially wasting the money, time, and energy of the mental health system (19). They will form the same attachments to their therapists as they do to other people, bristling at perceived abandonment, demanding huge amounts of attention, threatening suicide, and discontinuing treatment abruptly when split thinking causes a once idealized practitioner to become suddenly demonized.
Developed in the early 1990’s by Dr. Marsha Linehan, dialectical behavior therapy is currently the most accepted method of treating the multi-symptomed BPD population, and is now beginning to be used for people with other diagnoses (20). Namely, dialectical behavioral therapy’s goal, as its name suggests, is to replace rigid behavioral structures with a more fluid, rational way of thinking about a person’s own behaviors. This sort of skill-set training, common to most cognitive behavioral therapies, seems extremely logical in terms of treating a patient who suffers from an inability to think dynamically. It isn’t at all surprising that these methods would be central to helping a person deal with a relatively segregated mind. Still, what sets dialectical behavioral therapy apart is one of the crucial subsets of the treatment, during which it provides training in the practice of mindfulness, a melding of eastern Zen tradition and Western meditative strategies (20). DBT hinges on individual therapy sessions along with group training sessions and programs. It is always a time limited treatment, but its length and intensity can vary from a few hours a week of training for a year to fifteen or more hours a week over the course of 6 months. The program consists of four modules which are taught over the course of months of treatment: core mindfulness skills, interpersonal effectiveness skills, emotion modulation skills and distress tolerance skills (21).
In so many ways, the skills taught in mindfulness training seem to be at the crux of what is so different about DBT for patients with just the sort of proposed I-Function difficulties presented above. By virtue of the mindfulness techniques which involve breathing, relaxation, and meditation exercises, an I-Function who has distinct trouble letting go is encouraged to literally relax a bit, opening pathways in the brain and stimulating an awareness of other selves and options. Common among BPD patients is a sense that there is only one decision that can be made in a situation, that they don’t experience the level of free will that other people do, and it seems true that some of the abilities of the brain to check and balance itself are not as innate in people for whom splitting has become a pathology. Still, if the mind is opened up to itself a little, it can begin to build new strategies for continued integration.
As Dr. Linehan explains it, working with simply the behavioral aspects of the disorder in therapies did not help these BPD patients, as they were severely deregulated by criticism, which led to an inability to engage in therapy and either an immediate response of attack or withdrawal (1). Linehan developed the idea that in order to begin to change, expand, and amalgamate their disjointed narratives, patients would need to undergo a process of “radical acceptance,” understanding that they are who they are and the problems they have are the problems they have, and she realized that this could be facilitated using Zen-based techniques. Particularly, there are six subsets of this mindfulness skill: noticing what is happening in one’s mind without trying to specifically engage in it, describing something without translating it, fully engaging in activities, non-judgmental thinking, experiencing a moment without extending it to the past or future, and focusing on what works and what doesn’t rather than whether personal assumptions were correct or incorrect (1). Linehan and others have done a number of studies, and most seem to demonstrate that DBT is more effective in treating the symptoms of borderline personality disorder than other current options (22, 23, 24). Kathleen, quoted above, says that after she underwent DBT things changed drastically in her behavior and ability to function. She went from being in and out of inpatient treatment to training for a master’s degree in social work and studying to treat patients with personality disorder.
I mean, the difference being now is that when I feel upset aboutsomething, I don't go home and overdose on pills. I--I don't have the--I don't have that need anymore. There are other things I can do. I can go for a long walk. I can call friends. I can eat ice cream. I can whatever, but, you know--I mean, before I would immediately go home and feel like I had to punish myself somehow because I was so stupid, I was so disgusting, I was so ashamed of myself. And that doesn't happen anymore. (1)
The amazing thing about DBT is not that it has solved the puzzle of BPD – it is not by any means a cure-all, and people in DBT programs still commit suicide, still complain of feelings of emptiness, and still occasionally fail to integrate the various facets of the mind in the way they might wish. But what is remarkable in the story is that, by looking at the brain in new ways, and considering what works and what doesn’t, a problem with no answer can be gotten less wrong. There are still many, many questions to be asked, and methods to be tried. What other options are there for helping a mind literally be able to hear itself think? Might a program of neurofeedback help facilitate new pathways between the various selves in a mind, just the way mindfulness has, or perhaps even better? What aspects of DBT are the crucial ones, the ones that help? Could a carefully constructed psychodynamic therapy, coupled with mindfulness, or neurofeedback, or another technique, work just as well (25)? How important is the group component in DBT – are the tacit and I-Function selves able to mirror within a mind the cooperative behavior facilitated in multi-person skill training sessions? The questions are numerous, maybe more numerous than they were before DBT demonstrated that there were, in fact, more possibilities for this population of people than previously thought. What is incredible is that questions exist at all, that room can be allowed for the possibility of relief. There is space for research where quite recently there was none. This beast is a many-tentacled-thing, or, in reality, a many-tentacled-things, and it is unlikely that a uniform cure will ever exist to treat each person who presents with some of the symptoms currently under the rubric of borderline personality disorder. Still, what can be gleaned is that increased thought about how a brain interacts with itself can lead to breakthroughs in how we facilitate that interaction. Once we allow for the possibility that things can be gotten less wrong, we can concentrate on how to get them even less wrong than less wrong.
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