I Hate You--Don't Leave Me - Jerold J. Kreisman [58]
Abby, a twenty-three-year-old fashion model, was treated in a chemical dependency unit for alcoholism. She responded very well to this program, but as she continued to abstain from alcohol, she became increasingly, compulsively bulimic. She then entered an eating-disorders unit where she was again successfully treated.
A few weeks later, she began experiencing severe panic attacks in stores, offices, even while driving in her car, and eventually became afraid to leave her house. In addition to these phobias, she was becoming more depressed. As she considered entering a phobia clinic, a psychiatric consultant recognized all of her symptoms to be representative of BPD and recommended instead that she enter a psychiatric unit specializing in borderline conditions. Where her previous treatments had focused exclusively on alcoholism or bulimia, this hospitalization took a more holistic view of her life and treatment.
Eventually, Abby was able to connect her problems to her continued ambivalent relationship with her parents, who had interfered with her attempts to separate, mature, and be more independent. She realized that her various illnesses were really means to escape her parents’ demands without guilt. Her bulimia, drinking, and anxieties occupied all her energy, distracting her from addressing the conflicts with her parents. What’s more, her “sick” role excused her from even feeling obligated to work on this relationship. Ironically, the illnesses also kept her attached to her parents: Because they had serious marital problems (her mother was an alcoholic and her father was chronically depressed), she could stay close to them by replicating their pathological roles.
After a brief hospitalization she continued individual outpatient psychotherapy. Her mood improved and her anxieties and phobias dissolved. She also continued to abstain from alcohol and purging.
Abby’s case illustrates how a consuming, prominent behavior may actually represent and camouflage underlying BPD, in which one or more of its features—unstable relationships, impulsivity, mood shifts, intense anger, suicidal threats, identity disturbances, feelings of emptiness, or frantic efforts to avoid abandonment—result in psychiatric symptoms that might mistakenly lead to incomplete diagnosis or even misdiagnosis.
Coping and Helping
It is important to remember that BPD is an illness, not a willful attempt to get attention. The borderline lacks the boots, much less the bootstraps, with which to pull himself up. It is useless to get angry or to cajole and plead with the borderline to change; without help and motivation he cannot easily modify his behavior.
However, this does not imply that the borderline is helpless and should not be held responsible for his conduct. Actually, the opposite is true. He must accept, without being excused or protected, the real consequences of his actions, even though initially he may be powerless to alter them. In this way, BPD is no different from any other handicap. The individual confined to a wheelchair will elicit sympathy, but he is still responsible for finding wheelchair accessibility to the places he wishes to go, and for keeping his vehicle in good enough condition to take him there.
The borderline’s extremes of behavior typically lead to either a hard-nosed “You lazy good-for-nothing SOB, pull yourself together and fly right” response, or a cajoling “You poor baby, you can’t do it; I’ll take care of you” pat on the head. All must be aware of how their interactions may encourage or inhibit borderline behaviors. Those who interact with a borderline must attempt to walk a very thin line between, on the one hand,