Interview with Dr. M. Gerard Fromm on Borderline Personality Disorder

Dr. Fromm, borderline personality disorder is often regarded as a controversial diagnosis and many people have a hard time grappling with it. Just what does BPD mean?
That’s a good question, and one that has intrigued me for some time. In the late 1980s and 90’s, the term became prominent in psychiatry — and it quickly became embedded in set of pejorative ideas and attitudes toward very difficult patients. I found this troubling, and joined the conversation with a paper called “What Does ‘Borderline’ Mean?” (Psychoanalytic Psychology, Vol. 12, No. 2, Spring. 1995, pp. 233–45.)

You wrote in that paper that “borderline” — and you put in quotations marks — “is not an entity, but rather a vast developmental territory of severe personality disturbance.”
Yes, it occurred to me that no patient has ever come into a doctor’s office and said, “I feel borderline today.” You do hear people say, “I feel anxious,” or “I feel depressed,” or, “I’m obsessing all day.” But the diagnosis of borderline doesn’t come from the patient’s experience of emotion or any kind of action referent. It is applied to sufferers, rather than coming from them. I would argue that the term actually applies to the clinician, who often feels a dilemma facing certain kinds of patients who really get under our skins. So we ask ourselves, “Is this neurosis? Is it psychosis? Is some kind of need coming at me that I need to address, or is there a demand that I need to set boundaries on?” It’s really the clinician at a borderline of some sort, asking, “Is it this or is it that?”

That said, both a person who “has” something called borderline — or is in relation to it — will experience profound interpersonal trouble. The person who gets the diagnosis, and those around them, feel a kind of instability relating to their sense of themselves. We could also call this an intense and sustained identity crisis. This might be expressed through their work or other aspects of their daily life. But most often it comes through in their relationships, which flame up, and die out just as quickly.

People with borderline are often associated with intensity and extremes.
Yes. Another way to describe the intensity issue is what we would think of as “affect regulation,” which means the person’s trouble controlling emotions, particularly the emotion of anger around loss. The emotional temperatures of these patients shoot up, and wreak havoc, and then fall just as rapidly, but often leadi to other people withdrawing from them. People we call borderline often leap into an intense relationship, and want to interpret it as much more serious than it is, and cannot stand either the humiliation of potential loss or, more seriously, the actual sense of rejection and abandonment. The “borderline” position is a highly relational one — it’s in relation to one other person.

In terms of assessing the line between neurosis and psychosis, the psychoanalyst Otto Kernberg, who directs the Personality Disorders Institute of the New York Hospital-Cornell Medical Center, argues that there are three relevant categories. First, the ability to test reality — to know what’s real from what’s fantasy. Second, the ability to integrate oneself so you have a sense of being a distinct, whole human being. And third, the ability to differentiate oneself from others, so you can tell what’s you and what’s them. A neurotic person can do all three. A psychotic person is vulnerable in all these areas A borderline person’s troubles begin at a point in life when they’ve matured enough to see themselves as a whole person, but remain very vulnerable to a loss of boundary between themselves and other people.

What do you suppose is happening for the suffering person, under the skin?
I would argue that the fear of abandonment is absolutely key, and that it’s that fear that provokes so much instability in work life and, especially, in personal life. Usually when people break out into something called borderline, their sense of themselves in relationships tends to have a deep contradiction. They simultaneously feel that they are way too much for another person — that no one can stand the intensity of their feelings or the idiosyncracies of their inner life — but also that they’re not enough. They feel a weakened sense of self. They’re dependent on another person’s presence to avoid isolation and abandonment, and yet they feel they’re not enough to hold the other person with them, and then that their anxiety-driven emotions will drive away the person they most need. It’s an impossible spot.

In short, they’re terrified of being left alone. Just terrified. And when that comes up, they can become easily enraged, and frantic to do something about it. It’s such a terror that they don’t actually allow the feeling to happen. It’s so hard to sit with this feeling. In some ways, to feel lonely is an advance for this kind of person because it allows them to tolerate aloneness without feeling overwhelmed. Our effort in treatment is to help people sit with painful feelings and learn to tolerate them without feeling it is the end of the world. In these frightened states, there’s no time frame, everything is now. It is a revelation for a person to see it’s not always going to feel this way, feelings are feelings, they do not condemn a person to a permanent and terrible fate.

And they pass rather quickly if one lets them?
That’s right, though the relationship issues that lead to the bad feelings need to be grasped and changed. The Lacanians talk about three orders of experience: First, real order: the raw, emotional experience that borders on actual trauma. Second, the imaginary order: for the person in the borderline spot, they feel attuned to one other person and they are in heaven in that brief moment when they can talk themselves into the illusion that the other person will always be with them, and they are in hell when that falls apart. That is a kind of imaginary bubble the person is constantly caught up in. And third, there is the symbolic order: everyday laws, roles, and language, putting things into a perspective that includes a reality larger than both people and that situates the person in an ordinary understanding of how people work. That stage is very hard for a person in this borderline state to get to, so in the midst of a breakdown moment of such intense experience, you see behavior that feels so outrageous, so apart from ordinary ways people might operate that it tips you off that an extreme condition is in front of you. In a state like this, the person seems shameless, but when it’s over, the sense of reality returns and, along with it, a deep sense of shame.

Interview with Dr. Jerry Fromm Continued page 2