边界人格障碍 Borderline Personality Disorder
陈俊伉
Borderline Personality Disorder
Borderline Personality Disorder (BPD) is one of the most controversial
diagnoses in psychology today. Since it was first introduced in the
DSM, psychologists and psychiatrists have been trying to give the
somewhat amorphous concepts behind BPD a concrete form. Kernberg's
explication of what he calls Borderline Personality Organization is the
most general, while Gunderson, though a psychoanalyst, is considered by
many to have taken the most scientific approach to defining BPD. The
Diagnostic Interview for Borderlines and the DIB-Revised were developed
from research done by Gunderson, Kolb, and Zanarini. Finally, there is
the "official" DSM-IV definition.
Some researchers, like Judith Herman, believe that BPD is a name given
to a particular manifestation of post-traumatic stress disorder: in
Trauma and Recovery, she theorizes that when PTSD takes a form that
emphasizes heavily its elements of identity and relationship
disturbance, it gets called BPD; when the somatic (body) elements are
emphasized, it gets called hysteria, and when the
dissociative/deformation of consciousness elements are the focus, it
gets called DID/MPD. Others believe that the term "borderline
personality" has been so misunderstood and misused that trying to
refine it is pointless and suggest instead simply scrapping the term.
What causes Borderline Personality Disorder?
It would be remiss to discuss BPD without including a comment about
Linehan's work. In contrast to the symptom list approaches detailed
below, Linehan has developed a comprehensive sociobiological theory
which appears to be borne out by the successes found in controlled
studies of her Dialectical Behavioral Therapy.
Linehan theorizes that borderlines are born with an innate biological
tendency to react more intensely to lower levels of stress than others
and to take longer to recover. They peak "higher" emotionally on less
provocation and take longer coming down. In addition, they were raised
in environments in which their beliefs about themselves and their
environment were continually devalued and invalidated. These factors
combine to create adults who are uncertain of the truth of their own
feelings and who are confronted by three basic dialectics they have
failed to master (and thus rush frantically from pole to pole of):
* vulnerability vs invalidation
* active passivity (tendency to be passive when confronted with a
problem and actively seek a rescuer) vs apparent competence (appearing
to be capable when in reality internally things are falling apart)
* unremitting crises vs inhibited grief.
DBT tries to teach clients to balance these by giving them training in
skills of mindfulness, interpersonal effectiveness, distress tolerance,
and emotional regulation.
Kernberg's Borderline Personality Organization
Diagnoses of BPO are based on three categories of criteria. The first,
and most important, category, comprises two signs:
* the absence of psychosis (i.e., the ability to perceive reality
accurately)
* impaired ego integration - a diffuse and internally contradictory
concept of self. Kernberg is quoted as saying, "Borderlines can
describe themselves for five hours without your getting a realistic
picture of what they're like."
The second category is termed "nonspecific signs" and includes such
things as low anxiety tolerance, poor impulse control, and an
undeveloped or poor ability to enjoy work or hobbies in a meaningful
way.
Kernberg believes that borderlines are distinguished from neurotics by
the presence of "primitive defenses." Chief among these is splitting,
in which a person or thing is seen as all good or all bad. Note that
something which is all good one day can be all bad the next, which is
related to another symptom: borderlines have problems with object
constancy in people -- they read each action of people in their lives
as if there were no prior context; they don't have a sense of
continuity and consistency about people and things in their lives. They
have a hard time experiencing an absent loved one as a loving presence
in their minds. They also have difficulty seeing all of the actions
taken by a person over a period of time as part of an integrated whole,
and tend instead to analyze individual actions in an attempt to divine
their individual meanings. People are defined by how they lasted
interacted with the borderline.
Other primitive defenses cited include magical thinking (beliefs that
thoughts can cause events), omnipotence, projection of unpleasant
characteristics in the self onto others and projective identification,
a process where the borderline tries to elicit in others the feelings
s/he is having. Kernberg also includes as signs of BPO chaotic, extreme
relationships with others; an inability to retain the soothing memory
of a loved one; transient psychotic episodes; denial; and emotional
amnesia. About the last, Linehan says, "Borderline individuals are so
completely in each mood, they have great difficulty conceptualizing,
remembering what it's like to be in another mood."
Gunderson's conception of BPD
Gunderson, a psychoanalyst, is respected by researchers in many diverse
areas of psychology and psychiatry. His focus tends to be on the
differential diagnosis of Borderline Personality Disorder, and Cauwels
gives Gunderson's criteria in order of their importance:
* Intense unstable relationships in which the borderline always
ends up getting hurt. Gunderson admits that this symptom is somewhat
general, but considers it so central to BPD that he says he would
hesitate to diagnose a patient as BPD without its presence.
* Repetitive self-destructive behavior, often designed to prompt
rescue.
* Chronic fear of abandonment and panic when forced to be alone.
* Distorted thoughts/perceptions, particularly in terms of
relationships and interactions with others.
* Hypersensitivity, meaning an unusual sensitivity to nonverbal
communication. Gunderson notes that this can be confused with
distortion if practitioners are not careful (somewhat similar to
Herman's statement that, while survivors of intense long-term trauma
may have unrealistic notions of the power realities of the situation
they were in, their notions are likely to be closer to reality than the
therapist might think).
* Impulsive behaviors that often embarrass the borderline later.
* Poor social adaptation: in a way, borderlines tend not to know or
understand the rules regarding performance in job and academic
settings.
The Diagnostic Interview for Borderlines, Revised
Gunderson and his colleague, Jonathan Kolb, tried to make the diagnosis
of BPD by constructing a clinical interview to assess borderline
characteristics in patients. The DIB was revised in 1989 to sharpen its
ability to differentiate between BPD and other personality disorders.
It considers symptoms that fall under four main headings:
1. Affect
* chronic/major depression
* helplessness
* hopelessness
* worthlessness
* guilt
* anger (including frequent expressions of anger)
* anxiety
* loneliness
* boredom
* emptiness
2. Cognition
* odd thinking
* unusual perceptions
* nondelusional paranoia
* quasipsychosis
3. Impulse action patterns
* substance abuse/dependence
* sexual deviance
* manipulative suicide gestures
* other impulsive behaviors
4. Interpersonal relationships
* intolerance of aloneness
* abandonment, engulfment, annihilation fears
* counterdependency
* stormy relationships
* manipulativeness
* dependency
* devaluation
* masochism/sadism
* demandingness
* entitlement
The DIB-R is the most influential and best-known "test" for diagnosing
BPD. Use of it has led researchers to identify four behavior patterns
they consider peculiar to BPD: abandonment, engulfment, annihilation
fears; demandingness and entitlement; treatment regressions; and
ability to arouse inappropriately close or hostile treatment
relationships.
DSM-IV criteria
The DSM-IV gives these nine criteria; a diagnosis requires that the
subject present with at least five of these. In I Hate You -- Don't
Leave Me! Jerold Kriesman and Hal Straus refer to BPD as "emotional
hemophilia; [a borderline] lacks the clotting mechanism needed to
moderate his spurts of feeling. Stimulate a passion, and the borderline
emotionally bleeds to death."
Traits involving emotions:
Quite frequently people with BPD have a very hard time controlling
their emotions. They may feel ruled by them. One researcher (Marsha
Linehan) said, "People with BPD are like people with third degree burns
over 90% of their bodies. Lacking emotional skin, they feel agony at
the slightest touch or movement."
1. Shifts in mood lasting only a few hours.
2. Anger that is inappropriate, intense or uncontrollable.
Traits involving behavior:
3. Self-destructive acts, such as self-mutilation or suicidal threats
and gestures that happen more than once
4. Two potentially self-damaging impulsive behaviors. These could
include alcohol and other drug abuse, compulsive spending, gambling,
eating disorders, shoplifting, reckless driving, compulsive sexual
behavior.
Traits involving identity
5. Marked, persistent identity disturbance shown by uncertainty in at
least two areas. These areas can include self-image, sexual
orientation, career choice or other long-term goals, friendships,
values. People with BPD may not feel like they know who they are, or
what they think, or what their opinions are, or what religion they
should be. Instead, they may try to be what they think other people
want them to be. Someone with BPD said, "I have a hard time figuring
out my personality. I tend to be whomever I'm with."
6. Chronic feelings of emptiness or boredom. Someone with BPD said, "I
remember describing the feeling of having a deep hole in my stomach. An
emptiness that I didn't know how to fill. My therapist told me that was
from almost a "lack of a life". The more things you get into your life,
the more relationships you get involved in, all of that fills that
hole. As a borderline, I had no life. There were times when I couldn't
stay in the same room with other people. It almost felt like what I
think a panic attack would feel like."
Traits involving relationships
7. Unstable, chaotic intense relationships characterized by splitting
(see below).
8. Frantic efforts to avoid real or imagined abandonment
* Splitting: the self and others are viewed as "all good" or "all
bad." Someone with BPD said, "One day I would think my doctor was the
best and I loved her, but if she challenged me in any way I hated her.
There was no middle ground as in like. In my world, people were either
the best or the worst. I couldn't understand the concept of middle
ground."
* Alternating clinging and distancing behaviors (I Hate You, Don't
Leave Me). Sometimes you want to be close to someone. But when you get
close it feels TOO close and you feel like you have to get some space.
This happens often.
* Great difficulty trusting people and themselves. Early trust may
have been shattered by people who were close to you.
* Sensitivity to criticism or rejection.
* Feeling of "needing" someone else to survive
* Heavy need for affection and reassurance
* Some people with BPD may have an unusually high degree of
interpersonal sensitivity, insight and empathy
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms
This means feeling "out of it," or not being able to remember what you
said or did. This mostly happens in times of severe stress.
Miscellaneous attributes of people with BPD:
* People with BPD are often bright, witty, funny, life of the
party.
* They may have problems with object constancy. When a person
leaves (even temporarily), they may have a problem recreating or
remembering feelings of love that were present between themselves and
the other. Often, BPD patients want to keep something belonging to the
loved one around during separations.
* They frequently have difficulty tolerating aloneness, even for
short periods of time.
* Their lives may be a chaotic landscape of job losses, interrupted
educational pursuits, broken engagements, hospitalizations.
* Many have a background of childhood physical, sexual, or
emotional abuse or physical/emotional neglect