Borderline Personality Disorder

From the Patient’s Perspective

Sharon Glick Miller, Ph.D. ence could help expand clinicians’ Participants in the study were pa-
understanding of borderline person- tients at the University of South
Objectiws: Patients with a diag- amy disorder and its treatment. Florida Psychiatry Center who met
nosis ofborderlinepersonality dis- The study reported here focused the diagnostic criteria for borderline
order were studied to learn how on two questions: first, how mdi- personality disorder as confirmed by
they experienced the disorder and viduals with a diagnosis of border- both the Structured Clinical Inter-
its treatment. Methods: Life history line personality disorder perceive be- view for DSM-III-R-PD (7) and the
narratives were obtainedfrom ten ing in the world, or how they they Diagnostic Interview for Borderlines
patients with borderline personal- experience and are involved in their (8). The ten subjects had been re-
ity disorder in a series of 90-mm- social context, and, second, how they ferned by eight therapists, and nine
ute interviews held over the course experience the disorder and its treat- ofthe subjects also had one ofthe axis
ofayear. The interviews bad mini- ment. The study sought to deter- I diagnoses: four patients had major
ma! structure; patients were sim- mine the experiential correlates of depression, recurrent and unspeci-
ply asked to talk about themselves. the identified features ofthe disorder fled; one had psychotic disorder not
Results: The narratives revealed and the meaning ofpatients’ symp- otherwise specified; one had post-
striking similarities in the pa- toms in relation to their life experi- traumatic stress disorder; one had
tients’ experience with borderline ence. dysthymia; one had generalized
personality disorder. Reports of anxiety disorder; and one had bu-
their experience d:ffered markedly Methods limia nervosa.
from clinical descriptions of the The study and the questions it posed
The subjects consisted of eight
disorder. Common themes of es- required a qualitative research de-
women and two men ranging in age
trangement, inadequacy, and de- sign, which is appropriate for an in-
from 2 1 to 50 years. All were Anglo-
spair were identified, as well as ductive investigation. This design
Saxon Protestants raised in lower-
common coping strategies, pri mar- also yields a context-embedded de-
middle-class households. Their his-
ily dissociation and avoidance of scniption central to the investigation
tories revealed no common charac-
self-disclosure. Conclusions: Pa- of life experience. The life-history
tenistics, such as being victims of
tients’ experiences with borderline method (1-5), in particular, was best
abuse or family disturbance. Most
personality disorder were highly suited to this task because it clarifies
experience while eliciting a stable were single; two were married, and
consistent but differed markedly
description of self. Individuals with one was divorced. Three were em-
from clinical descriptions. The pa-
borderline personality disorder are ployed-as a store clerk, a technical
tient narrativesprovided informa-
often thought to have problems in writer, and a food service worker.
tion that couLd lead to more effec-
achieving an integrated sense of self. Another was working part time on
tive treatment ofthe disorder.
Therefore, the life-history method campus while attending college.
was chosen because it could reveal is- Once the diagnosis of borderline
In spite ofthe voluminous literature
sues related to self-presentation, personality disorder was confirmed
on borderline personality disorder,
such as degree of coherence and sta- by the structured interviews, the re-
little attention has been paid to the
bility. searcher interviewed each patient in
experience of patients with this dis-
The number of subjects in the a series of9O-minute meetings held
order as described in their own words
study was small (ten), which is a over the course of a year. The inter-
and evaluated by their own con-
structs. Elucidation of their expeni- norm in qualitative research. Be- viewer met with each patient an av-
cause few assumptions were made erage of six times. Meetings were
about what was on was not relevant, a discontinued when no new informa-
Dr. Miller is assistant professor in large number ofvariables were stud- tion was forthcoming from the pa-
the Department ofPsychiatry and ied holistically in one or more sub- tient.
Behavioral Medicine, University jects. Representational samples are Only minimal structure on prod-
of South Florida, 3 5 1 5 East not needed for research that aims to ding was provided in the interviews.
Fletcher Avenue, Tampa, Florida generate and clarify descriptions of Patients were simply asked to tell
33613. patient life experiences (1,6). the researcher about themselves.

Hospital and Community Psychiatry December 1994 Vol. 45 No. 12 1215

They were not asked specifically to Although the etiology of borderline perceived social standards. Rather
talk about their experience as a pa- personality disorder may be multidi- than having an impaired sense of self,
tient with borderline personality mensional and involve a confluence they seemed to have a sense of them-
disorder, because no assumption was ofvarious biological and psychologi- selves as impaired.
made about whether the disorder cal factors, the resulting chronic dis- The patients reported trying a va-
was central to the patient’s expeni- tress follows a common pattern of niety of strategies, in an attempt to
ence. What patients chose to tell manifestation, one that may not be feel better, that might look like iden-
about themselves and how they unique to borderline personality dis- tity diffusion to an observer. Some
chose to do it was left to them. order and could reflect the expeni- made changes in their appearance,
Each session was tape recorded ence ofdistress in our culture. hoping that a change on the outside
and transcribed. The techniques of The marked divergence between would elevate their feelings. Others
grounded theory (9) were used to the patients’ descriptions of border- adopted different lifestyles. Many of
identify common themes and issues line personality disorder and de- their tactics could be labeled by oth-
in the narratives. Each transcript was scniptions by clinicians was also sur- ers as impulsive. Yet underneath this
reviewed for content and coded. For pnising. These differences are sum- flurry ofshifting behavior was a sta-
example, sentences describing feel- marized in Table 1. ble sense of self.
ings of inadequacy were coded “in- Just as superimposing two images Also contributing to the appear-
adequacy. “ Some of the codes were provides a perception of depth, su- ance of an identity disorder was the
then combined into categories or do- penimposing both clinicians’ and pa- patients’reluctance to reveal them-
mains. For example, “editing” (of tients’ descriptions of borderline selves, particularly to therapists, in
thoughts shared with others), “struc- personality disorder provides a more anticipation of disapproval. They
turing social interactions,” and “dis- accurate perception of targets for would rather be thought lacking an
sociating” were placed within the treatment. Toward that goal, the cx- identity than have their flawed iden-
larger domain ofcoping strategies. peniences of these patients are re- tities confirmed. Yet these patients
Once categories and subcate- viewed in terms ofhow they defined were open with the researcher for
gonies were generated, an attempt themselves, what being in the world reasons that are examined below.
was made to further define their rela- meant to them, their coping strate- The diagnosis of borderline per-
tionship. For example, with coping gies, their experiences as patients, sonality disorder was not part of
strategies, questions arose about and their reasons for self-disclosing these patients’ self-definitions, non
when one strategy was to be used for this research. were their axis I diagnoses. They
over another and with what conse- Self-definition. The subjects de- identified less with an illness than
quences. Redundancies across the fined themselves-their likes, dis- with a process ofstruggling through
case histories were then noted. likes, traits, and sense ofwho they li1 and trying to ameliorate feelings
were and who they wanted to be- of despair. References to this strug-
Results and discussion cleanly and consistently oven the gle were central in their narratives, as
The heterogeneity within the diag- course of the meetings. The patients indicated by the following descnip-
nostic category ofborderline person- made distinctions between the times tion of what being in the world
ality disorder has been the subject of they could be themselves and when meant to them.
some discussion. Because borderline they could not, either because of try- Being in the world: estrange-
personality disorder and other per- ing to please others or trying not to ment, inadequacy, and despair.
sonality disorders overlap signifi- let their insecurities show. Their Each patient in the study made mul-
cantly (10-16), with the average pa- presentation implied a core identity. tiple references to feeling estranged.
tient meeting the criteria for three
Common to all the patients was a Some examples are highlighted in
personality disorders, some authors
view ofthemselves as estranged from Table 2. Some reported feeling es-
have referred to personality subtypes
others and inadequate in the face of tranged as children, whereas others
among persons with borderline per-
sonality disorder ( 17 1 8). Further,
,

most patients with borderline per-

Table I
sonality disorder also meet criteria
Descriptors ofborderline personality disorder by clinicians and patients
for at least one axis I disorder, which
results in potentially more personal- Clinician Patient
ity subtypes (18,19). Therefore, the
results were expected to show few Identity disturbance: impaired sense of Cohesive identity: sense ofimpaired self
common themes among the narra- self
tives and wide diversity within the Diffuse boundary between selfand other Rigidly demarcated boundary between
diagnostic category. selfand other
Contrary to expectation, the nan-
natives contained striking similari- Global avoidance ofbeing alone Situation-specific avoidance of being
alone
ties, and a very coherent description
emerged ofthe experience of patients Instability ofmood Chronic dysphoria
with borderline personality disorder.

1216 December 1994 Vol. 45 No. 12 Hospital and Community Psychiatry

 instead of always wanting it to go
Table 2
away,” they nonetheless felt com-
Statements reflecting estrangement, inadequacy, and despair by patient with
pelled to try “something, anything,”
borderline personality disorder
when their feelings of distress were
severe. There was always the hope
Estrangement
that “just this once” something
I had a lot offriends, but I never flt part ofthe group.
would help. Their coping strategies
Even when very young, taking the bus to kindergarten, feeling like I wasn’t part of
correspond with the symptoms asso-
the people on the bus.
ciated with borderline personality
I felt .separated
. . in a way, not quite in there with the rest.
disorder.
I think it is because I already feel I’m different, so I feell should separate myself from
Dissociation was the predomi-
everyone else in some way
nant coping strategy. All knew how
Inadequacy to “block out feelings,” to “remove
What has always been there, for as long as I can remember, even back in school, even [themselves] emotionally,” to “numb
in middle school. . is like a rating scale.
. I don’t give people numbers. I just . . .
out,” or to “shut down.” When they
rate them against me and I never met anyone that I was equal to or better than,
could not blunt their feelings in this
no matter what. Even if it is a bum on the street, there is something
. . . that
makes him better than me. It is not that I have done anything bad; it islike what way, they resorted to distracting
I was born into. themselves with a flurry of activities
I have such low esteem ofmyself. I am constantly comparing. I feel that everyone . . .
or with alcohol on drugs.
is superior to me. Everyone. And I am not worthy. Patients viewed their apartment
I feellike I am not up to standard for something. . I always feel there is something . .
or their bedroom as a safe haven, a
lacking and so I look at other people to see if they feel the same way and they “sanctuary” to which they could ne-
don’t. So I compare
. . .myselfwith other people. There is this constant civil . . . treat, except at times when they felt
wan going on inside my head-who I want to be and who I’m stuck with. extremely depressed. Then it was
I can’t explain it, but you feel you’re useless,
. . . you’re worthless. dangerous for them to be alone be-
I am already bad enough. [By bad, you mean?] Not worthy, not meeting society’s cause the impulse to hurt themselves
standards. was greatest. Also, at such times they
Despair were in danger oftaking increasingly
The main thing is that you want to die. You want to be out of this life, out of the large amounts of medication to
pain. I don’t think there is anything anyone can do to make me feel differently. achieve some relief but usually suc-
I wouldn’t wish this upon someone else. Ifsomeone said you could get rid of it by ceeded only in overmedicating
giving it to someone else, I don’t think I would do it knowing what I have been themselves. Most had learned to
through. avoid being alone at these times and
I don’t know ff1 would have the nerve to kill myself. I feel like it a lot, and I think used the strategy ofgoing to a shop-
about it a lot, at least once a week. ping mall, where they were out of
danger but could avoid the demands
and anxieties associated with social
reported becoming aware ofthis feel- have done anything bad; it is like contact.
ing in adolescence. Most were un- what I was born into.” The patients used elaborate
aware of the origin and said that The sense ofemotional pain con- strategies to structure social interac-
it existed in spite of their having veyed by these patients was over- tion, which was anxiety provoking
obtained traditional markers of whelming. It could be detected in for all of them. Could they contnib-
achievement, such as good grades their words and their voices. It was ute to the conversation? Would they
and friends. However, two patients something they felt, thought about, be accepted or rejected? Even those
pointed to disturbances in their and took actions to mitigate. Each who presented as outgoing men-
families as the source, and one pa- narrative contained at least one refer- tioned the need to “push through”
tient attributed the feeling to the ence to spending hours in bed cry- feelings of inadequacy. This effort
discrimination she had experienced ing. Each person revealed an even- would take a toll on them, and they
as an obese child. present wish not to be alive. Some of would later feel “like all the energy
Related to feeling estranged was the statements about their despair has left,” “like a bad hangover,” or
feeling inadequate. Each patient re- are presented in Table 2, although “like I want to get drunk.”
ferred to comparing on rating him- much of the impact may be lost Social anxiety was managed in
selfor herselfagainst others and al- without hearing the pain in their consistent ways. Group situations in
ways falling short, even “if it is a voices on experiencing the nedun- which others carried the conversa-
bum on the street,” as one patient dancy ofsuch comments in the nan- tion were always preferred. Going
said. “Not worthy,” “lacking,” and ratives. outside to smoke was often used as an
“not meeting society’s standard” Coping strategies. Although excuse to distance themselves from
were frequent self-descriptions. The these patients had come to view their the group when feeling anxious.
common sentiment was, as one pa- despair as chronic and had decided Most restricted their relationships to
tient expressed it, “It is not that I they were better off “accepting that ones in which they felt in control,

Hospital and Community Psychiatry December 1994 Vol. 45 No. 12 1217

such as their occupational role on vol- like you feel better even though you searcher by revealing their worries or
unteer position. still want to die.” This was true even struggles.
Notably absent as a coping strat- for those who had had hospitaliza- On reflection, it is apparent that
egy was use of social support. Even tions ofnine months or longer. the research interview provided the
individuals who were married or had The patients’ reluctance to filly ideal form of social contact for these
a supportive extended family were disclose their negative feelings was individuals. It was a structured situ-
reluctant to share their feelings. also manifested in outpatient treat- ation in which they had some con-
They did not want to burden anyone, ment. They reported feeling in a trol. They had a right to withdraw
feared rejection, and, given the bind because lack ofdisclosure was from the study at any point, as noted
chronicity of their distress, also as- perceived as their not working in in the informed consent. Also impor-
sumed people would tire of hearing therapy, whereas disclosure would tant, perhaps, was that they entered
them repeat the same issues. In light reveal a lack ofprogress and might the relationship with some degree of
of the large body of literature that equality. They were the “experts” on
identifies the important role of social their experience, and the research
support in mitigating symptoms was clearly a collaborative process.
and facilitating recovery, it is signifi- Notably absent as a Participation in the research pro-
cant that these individuals did not coping strategy was vided both the safe social interaction
share their struggles with others and use of social support. and the social validation for which
were very isolated in their expeni- they were starved.
Patients did not want to
ences. The patients’ self-disclosure in
Thepatient experience. In refer- burden anyone, feared the study led to their feeling under-
ring to their experience as patients, rejection, and assumed stood. Almost all of the patients
the subjects underlined two areas of people would tire of noted spontaneously that they felt
conflict: they did not agree with more understood by the researcher
hearing them repeat
their therapist’s opinion on the role than by friends on family, and, in
ofhospitalization, and in spite of be- the same issues. some cases, than by their therapists.
ing encouraged in self-disclosure by Understanding may have been con-
their therapist, they avoided doing veyed by the fact that no challenges
so because they believed it could lead result in increased pressure by the were made to what they presented.
to behavior by the therapist that they therapist or the threat of hospitaliza- Also, the researcher had the luxury of
considered negative, such as invol- tion. In addition, they all refrmned to being able to listen without being
untary hospitalization. the difficulty they had in articulat- responsible for facilitating change
The purpose ofhospitalization for ing their problems. and was protected from, and there-
these patients was asylum-respite Self-disclosure and the research fore did not communicate nonver-
from their day-to-day struggle. process. If patients with borderline bally, any feelings of frustration.
Given their expectation of respite, personality disorder do not disclose Clinical implications. For those
one can see why they might look re- the details of their distress to those with a diagnosis of borderline per-
greased on admission. Some ne- around them, why would a re- sonality disorder, life seems like a
sponded to intense treatment by us- searcher be privy to them? Although game that is stacked against them.
ing negative behavior to emphasize it should not be assumed that they They wish they were not alive so they
their distress. Further, once they had withheld nothing, the question would not have to play, but they per-
had some respite and flt their crisis arises as to why they revealed as severe, with much of their behavior
to be oven, they wished to be dis- much as they did. reflecting or communicating their
changed. They hated that discharge One patient who was questioned distress. Their sense of marginality
was out oftheir control and that a le- about his openness with the re- and inadequacy needs to be under-
gal restraining order could prevent searcher explained that “I said I stood as more than just the result of
it. As one participant said, “I feel at a would help and that meant telling developmental history. It must be
loss because they can drag me into a you everything.” There was an em- recognized as a present dynamic. As
courtroom and hold up my arms phasis on the words “I would help,” Hall (20) has explained, “It is the
[pointing to his scars] and prove I making it clear that he had a role to corrosive daily frustration, the in-
have harmed myselfin the past. . . I. play and something to contribute. ability to communicate and establish
hate being in the hospital, but when His comment was echoed by the oth- meaningful relationships that is so
I get to a certain point, that is where ens in the study. Many also said that soul-shrinking.”
I want to be.” because the research process was not The clinical relationship often
All of these patients learned that therapy, it was safer to say many serves as the first context in which
they could not nefn to their thoughts things. They did not have to worry individuals experience themselves in
ofself-harm, an almost constant fa- that their disclosure might result in new ways. The hierarchical structure
ture oftheir lives. They learned that hospitalization. Further, as there was ofthe therapeutic relationship, how-
“to get out [of the hospital] you have no expectation ofchange, there was even, can inadvertantly reinforce the
to start faking it,” “to start acting no risk of disappointing the re- feelings of inadequacy and power-

1218 December 1994 Vol. 45 No. 12 Hospital and Community Psychiatry

lessness in patients with borderline pological Approach to Biography. No- al: Diagnostic overlap and internal con-
vato, Calif, Chandler & Sharp, 1988 sistency of individual DSM-llI criteria.
personality disorder. A collaborative
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The narratives also suggest why
group therapies can be an effective
component in the treatment of bor-
derline personality disorder (2 1) in Changes in Requirements for Papers Submitted
that they may begin to address issues
Authors preparing manuscripts for . Tohelpdarifytheextenttowhich
of estrangement, social validation,
HospitalandCommunity Psychiatry, to the findings ofa research study may be
and social support. One may hy- generalized to other populations,
be published under its new name,
pothesize that a group therapy de- authors should include data on the
Psychiatric Services, as ofJanuary 1995,
signed specifically to address issues should be aware of several changes sex, age, and race ofstudy subjects.
of social marginality, powerlessness, made recently in the journal’s re- S Beginning in January 1995,
and perceived inability to meet so- quinements related to submission of brief reports will carry abstracts.
cial expectations would be even more manuscripts for publication. The Authors are asked to submit a short
effective. current requirements are listed in abstract of no more than 100 words
the Information for Contributors with bniefreports submitted for pub-
published on pages 1081-1082 of lication. Structured abstracts are not
References the November issue. required for brief reports.
1 . Angrosino MY Documents of Interac-
S Authors must disclose finan- . Any computer-generated fig-
tion: Biography, Autobiography, and cial interests in products or services ures accepted forpublication must be
Life History in Social Science Perspec- described in the paper. A form de- printed on a high-resolution laser
tive. Gainesville, University of Florida scribing the kind of interests of po- printer. (Authors are reminded that
Press, 1989 tential concern will be sent to the figures should be submitted only
2. AngrosinoMY The two lives of Rebecca
corresponding author; it must be when they contain essential iafonma-
Levenstone: symbolic interaction in the
generation ofthe li1 history. Journal of completed and signed by all authors. tion that cannot be adequately pre-
Anthropological Research 45:315-326, S In the acknowledgments sec- sented in text or tables.)
1989 tion of the paper, besides listing fi- For further information, or for
3. BrunerJ: Acts ofMeaning. Cambridge,
nancial support (including drug copies of the Information for Con-
Mass, Harvard University Press, 1984
4. Denzin NK: Interpretive Biography. company support), authors must tnibutors, contact the Hospital and
Sage University PaperSeries onQualita- note any financial relationships that Community Psychiatry editorial office
tiveResearchMethods,vol 17. Newbury may pose a conflict of interest. (telephone, 202-682-6070).
Park, CaIif, Sage, 1989
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Hospital and Community Psychiatry December 1994 Vol. 45 No. 12 1219