Postcards from the Borderline

Mental health conditions have long been used as Hollywood plot devices. With greater awareness nowadays meaning we see fewer ‘mentally ill’ movie monsters, Lynne Marshall wonders why Borderline personality disorder seems to have been left out of the warm fuzzies.

One in fifty of the general population and one in five psychiatric inpatients suffer from Borderline personality disorder (BPD). Eight to ten per cent of BPD sufferers will attempt suicide, and many will succeed.

It does often surprise me that I’m not dead, what with one thing and another. Although I have never actually attempted suicide, I have regularly put myself in dangerous situations: drinking heavily, taking drugs and cutting myself. I’ve been hospitalised numerous times.

I was diagnosed in my early twenties. I was undergoing treatment for alcohol dependency at the time, but my psychiatrist felt there was something else going on too.

I was diagnosed with BPD in my early twenties. I was undergoing psychiatric inpatient treatment for alcohol dependency at the time, but my psychiatrist felt there was something else going on too. I didn’t understand the diagnosis at the time, perhaps because of the state of confusion brought about by whatever I was being prescribed.

Volatile relationships
‘You’re incredibly sweet and lovely, but you’re fucking mad,’ my ex-boyfriend continues to describe me. It’s true, we had a volatile relationship. All my relationships have been volatile; unstable relationships are often a feature of the disorder.

Ironically, it is usually the Borderline’s chronic fear of abandonment that leads them to push partners away by becoming overly possessive, aggressive or dependent. Many of those diagnosed with BPD have experienced a traumatic event in their past, such as abuse or neglect in childhood, or the death of one or both parents.

Borderline’s diagnostic criteria fits well with popular stereotypes of women as unstable, controlling and dependent.

Women significantly outnumber men in being diagnosed with BPD. Various theories exist on why this is. For example, it may be that men exhibiting Borderline symptoms are more likely to be diagnosed with substance abuse disorders, or paranoid, narcissistic, passive-aggressive, sadistic or antisocial personality disorders instead. Women are also more likely to report the physical and sexual abuse, eating disorders and identity disturbance that are criteria for the illness. Certainly Borderline’s diagnostic criteria fits well with popular stereotypes of women as unstable, controlling and dependent, so it could be that psychiatrists find it hard to see the same behaviour expressed by men for what it is.

Naming and shaming
Psychologist Adolf Stern wrote the first significant psychoanalytic work to use the term ‘borderline’ in 1938, in which he described a group of patients thought to have a mild form of schizophrenia, and ‘on the borderline between neurosis and psychosis’. BPD is also referred to, somewhat more informatively, as Emotionally unstable personality disorder. There are ongoing debates about renaming BPD; suggested alternatives include Emotional regulation disorder and Emotional dysregulation disorder. Post-traumatic personality disorganisation has also been suggested, due to its similarities with Post-traumatic stress disorder.

One of BPD’s most visible symptoms is impulsive, self-damaging behaviour: substance abuse, binge eating or food restriction, overspending or self mutilating, recurrent suicidal or parasuicidal behaviour (such as a sub-lethal drug overdose), unstable and intense personal relationships, and other characteristics as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

DSM diagnostic criteria for Borderline Personality DisorderA pervasive pattern of instability of interpersonal relationships, self-image, and affects, 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. Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealisation 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, eg, spending, sex, substance abuse, reckless driving, binge eating. Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
  5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
  6. Affective instability due to a marked reactivity of mood, eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger, eg, frequent displays of temper, constant anger, recurrent physical fights.
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

People with a BPD diagnosis may exhibit symptoms of anorexia, bulimia, compulsive overeating, self mutilation and neglecting to take medication. I have known two BPD sufferers who have also been diagnosed with epilepsy, and both of them have had periods where they have not taken their epilepsy medication, endangering themselves to the possibility of fits. Although substance abuse has long been my main self-harm, I never seem to be able to take my medication as prescribed, either taking the lot in one go or not taking it at all.

While I am frequently flippant about my BPD, the consequences, such as ending up in hospital after overdosing, often cause me deep regret.

My sense of self-preservation is inconsistent. While I am frequently flippant about my BPD, the consequences, such as ending up in hospital after overdosing, often cause me deep regret.

Self-harm goes mainstream
Self-harm came to the fore of popular culture during the 1990s. In an infamous Panorama interview, Princess Diana spoke of her self-harm and eating disorder. Richey Edwards, rhythm guitarist and lyricist of Manic Street Preachers, spoke openly of his depression, substance abuse and self harm in interviews, carving the words 4 REAL into his arm with a razor blade during an interview with a Radio One DJ, requiring hospitalisation and seventeen stitches.

The image of the self-harming emo has become engraved in the popular imagination. Razorblade motifs feature in jewellery that appears to be designed for girls as young as 10.

Portrayal in drama
Overt references to BPD in the media are rare; generally its appearance is surmised after the fact. Tellingly, most instances involved female sufferers, for which Shrieking Homicidal Harridan Personality Disorder would be a more fitting diagnosis.

An oft-stated instance of a BPD sufferer on celluloid is Glenn Close’s murderous stalker Alex Forrest in Fatal Attraction (1987), terror of philandering husbands and small fluffy things everywhere. Another notable instance is Jennifer Jason Leigh’s Hedy Carlson in Single White Female (1992). Although small fluffy things once again bear the brunt of Hedy’s strongly-suggested BPD – presumably having ‘a moment’, she is implied to have flung her new puppy out of her apartment window. As is usual for BPD-themed films, the denouement involves our sane heroine fighting for her life against the now openly monstrous Hedy.

Although amplification of reality may be necessary to provide drama, the reputation of a poorly understood syndrome can be significantly worsened by such hyperbole.

Rebecca de Mornay appeared as Mrs Mott in The Hand That Rocks the Cradle (1992), playing yet another woman who exhibits her jealousy and desire to protect others by going on a psychotic killing spree. Again, perfect housewife heroine Claire Bartel (Annabella Sciorra) administers a fairly unconventional form of psychiatric treatment, in the form of impaling the deranged monster on a fence.

Indeed, the strongly implied BPD sufferer finds mild reason to be upset, goes utterly bonkers, starts killing people trope appears continually, including in The Crush (1993), Presumed Innocent (1990) and Malicious (1995).

Although amplification of reality may be necessary to provide drama, its easy to see how the reputation of a poorly understood syndrome can be significantly worsened by such hyperbole.

Watching these depictions, I feel both angry and sad. I’ve done some really stupid things in the past but I am a bit of an extreme example, mainly because I can drink more in an evening than Hunter S. Thompson did in his whole life. The drinking seems to exacerbate the other problems, like getting arrested and so on. Not everybody with BPD is like me; all the sufferers I’ve known have been intelligent, gentle people. I don’t dismiss myself here, I’m an intelligent, gentle person too, though I do seem to enjoy pushing the envelope that little bit too far. I feel sad though, that I always seem to make the mistake of thinking people will see beyond the wall, as it were, because so many of my relationships have been damaged by my mental health. A lot of people I know with BPD seem to be very solitary, and those that are attached still have difficulty with interpersonal relationships.

‘[Fatal Attraction] is often cited as an example of a woman, Alex, having borderline personality disorder, even in some college psychology classes,’ says Kristalyn Salters-Pednault, PhD. ‘I do not know if the writers intended this, but regardless, it is a dangerous characterisation of the disorder.’

UK mental health charity Mind have recently started a project looking at the best and worst portrayals of mental health on television, and I am interested to see whether the results include some of the many examples of implied BPD.

Psychiatric perception

Clinicians have been known to claim that BPD does not exist, whereas at the other end of the spectrum, some refuse to diagnose the disorder because it is so stigmatising.

Worryingly, this perception of BPD sufferers as monstrous harpies is not limited to film, television and the general public. Even when BPD sufferers are not being cast as Jason Vorhees-wannabes with breasts, the disorder seems not to be taken seriously, despite both the comparatively high morbidity rate – how many people have it – and very high hospitalisation and mortality rate – how many people it kills. Clinicians have been known to claim that BPD does not exist, whereas at the other end of the spectrum, some refuse to diagnose the disorder because it is so stigmatising. In a paper published in the Harvard Review of Psychiatry in 2006 suggested that the common perception of BPD sufferers as being difficult, and the consequent distancing of their clinicians, creates a self-fulfilling prophesy:

‘Borderline personality disorder (BPD) is often viewed in negative terms by mental health practitioners and the public. The disorder may have a stigma associated with it that goes beyond those associated with other mental illnesses. The stigma associated with BPD may affect how practitioners tolerate the actions, thoughts, and emotional reactions of these individuals. It may also lead to minimising symptoms and overlooking strengths. In society, people tend to distance themselves from stigmatized populations, and there is evidence that some clinicians may emotionally distance themselves from individuals with BPD.

This distancing may be especially problematic in treating patients with BPD; in addition to being unusually sensitive to rejection and abandonment, they may react negatively (eg, by harming themselves or withdrawing from treatment) if they perceive such distancing and rejection.’

Treatment
Many psychiatrists believe BPD is untreatable. In the UK, the National Institute for Health and Clinical Excellence recommends against the use of medication for treating BPD, but supportive psychotherapy is thought useful in building self-esteem and existing strengths.

Recovery requires dedication – a belief in the possibility that therapy will help, a willingness to work on it, and a belief that with your illness controlled you will be genuinely happier.

As with any mental illness, recovery requires dedication – a belief in the possibility that therapy will help, a willingness to work on it, and a belief that with your illness controlled you will be genuinely happier. I’ve been fighting myself since I was about thirteen years old, nearly two decades ago. It’s a hell of an effort, and goodness knows if I can make it, but people with BPD do live with it, hold down jobs, have families and all that stuff.

Dialectical Behaviour Therapy, or DBT, is considered by many to be the best method of treatment. Some say that DBT is loosely based on Zen Buddhism: acceptance and dealing with things.

The jury’s still out on DBT, but I give it the thumbs up. It’s been more use to me than drug treatment or hospitalisation. I can wax lyrical about at times, especially when I’ve had a drink. I guess I’ll be better equipped to explain how this is going in a year or two’s time, but when I think of the BPD sufferers I know, I can see real futures for most of them, and interesting autobiographies.

Lynne Marie Marshall was born in Surrey and is not at all happy about it. She likes rubbish television from the 80s, tea, smoking and not being depressed. Supplementary film expertise provided by Charly Carr, who is similar in many ways, but wasn’t born in Surrey. Illustrations by Kate Lomax.

This article appeared in Filament Magazine Issue 4, March 2010. Unfortunately that issue is sold out, but you can still get our latest one here.

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