I have a beloved patient whose millennial daughter has proudly embraced her diagnosis of Borderline Personality Disorder stating that understanding this diagnosis has notably enhanced her self-awareness and capacity for forgiveness both of herself and, yes, of others. I am one of the first to argue that one should never embrace a diagnostic moniker as a global identifier, yet, here is a young woman who argues that the title is somehow grounding. As the mother of a man who suffers from a long-standing struggle with mind altering drugs, I have quietly wondered if my own child does not fall into the so-called Borderline spectrum as addictive behavior and emotional dysregulation are prominent features of his behavior and of the BPD diagnosis.
Because medical diagnosticians sadly painted addictive illness into a corner for fifty years, believing it to be a form of learned and “chosen” character defect, the individual with addictive illness often went without a psychiatric diagnosis of any kind as the clinicians waited for the confounding variable of addiction to be contained (i.e.: psychiatric diagnosis came only after a sustained period of total sobriety). Psychiatry only recently has begun to recognize and, yes, accept, that there are patients with co-occurring disorders ethically mandating that both categories of illness be addressed at the same time and not sequentially. Sadly, this being said, too few drug and alcohol treatment programs view addiction and, yes, Borderline Personality Disorder, as an illness.
In the early 1980’s, when I began my internship in a busy medical school psychiatry clinic, if truth be told, there was a quiet, unannounced pattern of never telling our patients that we suspected that they had the “label” of Borderline Personality Disorder. The reason for such subterfuge probably lies with the unstated professional belief that the diagnosis was somehow shaming and sadly impervious to treatment. Not only did we clinicians fear inviting a patient “meltdown” understanding that the diagnosis was stigmatizing and alienating but perhaps, many therapists understood the danger of their own subjective confusion about the diagnosis. For better or worse, the diagnosis of BPD remains a continuous thorn in the side of clinicians. The standard question that haunts the treatment providers is often one that finds them in the obfuscation of Bipolar Disorder-Borderline Personality Disorder symptom overlap. Even seasoned clinicians who readily know the nuances of the Psychiatric Diagnostic and Statistical Manual (DSM5) continue to muddy the diagnostic field with these two “conditions.”
You might wonder why this even matters but it matters very much. Let me explain why. First of all, personality disorders were not deemed responsive to biological interventions. As with addictive illness, personality or character (disorders) was seen to be the outcome of experience less than from biological roots or heritability. Freud took us down this dark, convoluted road blaming mothers and early child experience for the adult aberrant behavior and cognition. Alas, I am currently noting a form of replay of this Freudian philosophy when I hear clinicians arguing that all addictive illness or aberrant character is informed by childhood adverse events (aka: trauma). That being said, it matters very much whether clients receive a biological psychiatric diagnosis because, frankly, it gives them more gravitas with their providers and more opportunity for medical intervention.
Historically, patients with Borderline Personality Disorder and addictive illness were promptly dismissed from medical care and referred “out” to talk therapists. My own son, when receiving a medical assessment for Supplemental Security Income (SSI)) application was seen by the medical assessor for seven minutes. The addiction component in his co-occurring disorder immediately alerted the physician to his ineligibility for medical disability.
I have had a major epiphany regarding those diagnosed with Borderline Personality Disorder which might explain the shared phenomena of addictive behavior in both those with Obsessive-Compulsive Personality Disorder and Borderline Personality Disorder. Historically, we have envisioned these two very different types of brain wiring as linked with profoundly different types of people; those with high emotional regulation (the so called anxious good citizen-obsessive compulsives or “farmers”) and those with high emotional dysregulation (the in-the-moment, strategic, quick to rage-Borderline “hunters.”) The obsessive-compulsive good citizens were seen as fearing breaking rules that would offend others. The Borderline patients were wrongly perceived to have few or no rules guiding their behavior. I fear that we clinicians failed to recognize that patients with Borderline Personality Disorder do indeed have high anxiety informed by perceived breeches of their rules. In fact, the Borderline patient suffers a higher level of perceived emotional distress over even small assaults to their rules system. The so-called “farmer” might experience a small amount of annoyance were a friend to arrive late to a lunch date whereas the “hunter” would be furious and punitive.
So what is the component found in addictive illness shared by both the farmers and the hunters? I have to argue that it is anxiety! Historically, we have failed to see or worse yet have ignored anxiety in those in the narcissistic spectrum. Because the individual falling into the narcissistic spectrum is so often a risk-taker too often throwing caution to the wind, we think of these individuals as lacking protective anxiety. You know, the kind of anxiety that we farmers know as our braking mechanism.
That being said, the anxiety in those who struggle with emotional dysregulation is informed by a belief in one’s inherent unworthiness often masked by self-aggrandizement. Those with obsessive-compulsive behaviors know this same pain. They toil in the fields of perfection believing that their base commonness, their lack of perfection, makes them truly unlovable. However, believing in some form of future payoff, they embrace the Myth of Sisyphus pushing the rock up the mountain day after day as it continues to fall back down. It is not such a stretch of imagination to see how any compulsive behavior (workaholism, repetitive self-harm, anorexia, hoarding, gambling and drug and alcohol abuse) could create predictability that is otherwise missing. Addiction is the hand-maiden of unpredictable reward. And, if I am not being too reductionist, for the many who suffer from an alcohol disorder or opioid disorder, these drugs are experienced as anxiolytic and
bring true mental and physical peace for a few hours.
In conclusion, the sad truth is that while both hunters and farmers share some of the same roots of addictive illness, the course of remission is not the same. Again, looking at the variable of prefrontal foresight, it is much harder to “recover” (harm reductionists would say “achieve remission”) for those whose brains essentially trap them in the present. Sadly, this is true of those with Borderline Personality Disorder who have not had the advantage of treatments designed to arbitrarily improve foresight such as Mentalization Therapy (UCLA) and DBT(Marsha Lanahan, PhD.) The farmers, on the other hand, can innately visualize a future payoff informed by abstinence and dedication to a new path of health. For most farmers, there is the memory of a prior level of high-functioning that preceded the decline into addictive illness and the promise of a return to this gratifying state. This is less true for the hunters who frustrate easily and who have no abiding belief or internalized visual reminder of the future rewards of present-day vulnerability such as mandated residential treatment. Clearly, clinically-informed drug and alcohol treatment programs must work harder to understand that their clients are not all cut out of the same cloth and require sensitivity to these real brain differences.
Caroline Ridout Stewart recently retired from the UCSD Department of Psychiatry where she was a Clinical Instructor and Psychotherapist for over twenty years specializing in the treatment of anxiety and addictive illness. Caroline continues to be a harm reduction provider in her private practice where she enjoys working with those struggling with opioid misuse. She is the mother of a son who suffers from a co-occurring disorder and leads the local NAMI Co-Occurring Support Group for Family Members whose children suffer from both mental and addictive illness. Caroline has been the President of the board of A New PATH (Parents for Addiction Treatment and Healing). www.anewpath.org