Borderline Personality Disorder: A Conversation with M. Gerard Fromm, PhD, ABPP
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 leads to other people withdrawing from them. People we call borderline often leap into an intense relationship, and want to interpret it as more 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, MD, 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.
This six-part series, exploring borderline personality disorder, is taken from an interview, conducted by former Erikson Scholar Joshua Wolf Shenk in 2009, with M. Gerard Fromm, PhD, ABPP, a senior consultant to the Erikson Institute for Education and Research at the Austen Riggs Center.