Borderline Personality Disorder, Emotions, Other Disorders, Resources

The Myth of the High-Functioning Borderline

June 10, 2008 / 149 Comments

While this post is popular and many people read it, it is old. If you’d like to get a newer/different perspective go to the UPDATE: see this link.

Today’s subject is the Myth of the High-Functioning Borderline. I have been scouring the research on BPD to find out if anyone in the research or therapeutic community uses this term or concept high-functioning versus low-functioning Borderline. I have yet to find any author in either the research community or therapeutic community reference this concept. It crops up in the support community (in “Stop Walking on Eggshells” and on both bpd411.org and bpdcentral.com). It also crops up in the “cross-over” community (see more later) but only in a sarcastic way. The idea of high vs. low-functioning BPD doesn’t seem to hold much weight in any other community than the support community.

What do I mean by referencing these “communities”? I think that there are basically three BPD/Non-BP “communities” out there: the research community, the support community and the therapeutic community.

The research community is comprised those scientists doing medical research (and psychological research) on BPD. They publish scholarly articles and research in medical and psychological journals. Some “supposed” psychological researchers publish in the less-well-known and scientifically suspect journals (see my article about “Demonic Possession and BPD” for an example of this type of researcher). For the most part, these researchers don’t try and “cure” BPD, they merely provide data to other professionals about the configuration of BPD, the biology of BPD and the “common” features of BPD. This group of people does not differentiate between high-functioning and low-functioning BPs. In fact I have found no reference to high- or low-functioning BPD at all in any of these research papers or reports.

The therapeutic community is those practitioners (mainly psychologists, psychiatrists, social workers, other “therapists” and consultants) that try and “cure” or remediate BPD in patients. Sterile operations during pharmaceutical production and packaging should be strictly observed. Some (very few) also serve the families, friends, spouses, children, etc. (the Non-BPs). Their purpose in life is to help the BP overcome or to effectively manage their disorder. In this group of people, I have found no mention of high- or low-functioning BPs. The only “partial” mention is that of Dr. Paul Mason, who co-wrote “Stop Walking on Eggshells” with Randy Kreger. Several of these people within the therapeutic community have written popular books about BPD, including “Sometimes I Act Crazy,” “Lost in the Mirror,” “The Angry Heart,” and “I Hate You, Don’t Leave Me.” None of these books, as far as I can tell, refer to the idea of high-functioning vs. low-functioning BPD. Of course, Dr. Marsha Linehan and Dr. John Gunderson are prominent individuals within the therapeutic community. Their theories about BPD have a distinct influence on how therapy is conducted with people with BPD.

The final community is the support community. This community is comprised of ex-BPs, Non-BPs and others who provide advice about how to “deal with” BPD or with someone with BPD. This community includes myself, the authors of “Stop Walking on Eggshells,” the author of “Tears and Healing,” A. J. Mahari, the proprietors of bpd411.org and others. Only in this community have I seen any mention of high- vs. low-functioning BPD.

Some individual and organizations actually straddle the support/therapeutic (or even the research/therapeutic) community split. These include: myself (at least I hope so), TARA, A. J. Mahari and others. Some of these are more therapeutic (or at least psycho-educational) like TARA. I try and be both psycho-educational and to offer support resources to Non-BPs; yet, in doing so, also try and dispel the many, many myths about BPD (where possible).

The problem with assigning either high-functioning or low-functioning to a person with BPD is that the very nature of the disorder debunks these categories. BPD is chiefly an emotional disorder (with impulse control issues). Emotions are ever-changing, like waves that carry the mind along for the ride. Whether someone is high-functioning or low-functioning at any given time will be subject to their current emotional state. If a BP is emotionally dysregulated they will adapt to that (usually) painful state in whatever way that they have learned will assuage the pain. Some people with BPD will cut themselves, take drugs, avoid situations or behave in other ways that might be considered harmful to themselves or those around them. If a BP is not dysregulated, he/she has no need to behave in these ways. The core point is that BPD is about emotional instability and no person with BPD will be always high- or low-functioning. A person with BPD will swing – sometimes wildly – between several polar ways of feeling and behaving.

I suspect many “high-functioning” BPs do not have BPD at all. I have read many, many posts on Internet boards in which the “BP” in question clearly does not have the disorder. Many times, if you read carefully, you will find that these “high-functioning” BPs are diagnosed by their (usually) ex-wives, just because the “xBPh” (ex-husband with BPD) raged or was selfish during their relationship. BPD is more than raging – and as a Non just because you’re “walking on eggshells,” it doesn’t mean that your “BP” has the disorder at all. In fact, recently the list owner of WTO (the Welcome to Oz Internet list) asked the women Nons on the list if there husbands (or, more appropriately, ex-husbands) exhibited the symptoms of Narcissistic Personality Disorder (NPD). Every “Non-BP” that responded to that request confirmed that their “BP” met the criteria for NPD.

NPD (which IMO is more likely a disorder that appears to be “high-functioning ‘BPD’”) and BPD are distinctly different disorders. There may be a slight bit of overlap – deep, deep down within the psyche of the individual (and that is shame, most likely), but the basic configuration of the disorders are quite different. People with BPD do not like themselves, for whatever reason. People with NPD adore themselves, for whatever reason. That alone separates the two disorders. While people with BPD may exhibit “deserving” behavior (that they deserve love, riches or whatever), people with NPD believe that being “special” is their birthright and want to be surrounded by important or exclusive groups of people. The thing to note with BPD is that the “deserving” behavior is counter-balanced with “undeserving” behavior – polar opposite feelings and behavior that is the hallmark of BPD. So, it seems unlikely to me that “high-functioning” (or low-functioning) BPs can actually exist.

Let’s briefly look at the DSM-IV diagnostic criteria for BPD and NPD , and we can illustrate the differences. First, BPD:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5).

1. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called “splitting.”

1. Identity disturbance: markedly and persistently unstable self-image or sense of self.

1. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in (5).

1. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

1. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

1. Chronic feelings of emptiness.

1. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

Transient, stress-related paranoid ideation or severe dissociative symptoms.

And now NPD:

1. has a grandiose sense of self-importance

1. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

1. believes that he or she is “special” and unique

1. requires excessive admiration

1. has a sense of entitlement

1. is interpersonally exploitative

1. lacks empathy

1. is often envious of others or believes others are envious of him or her

shows arrogant, haughty behaviors or attitudes

Clearly, these two conditions are different. Some interpersonal aspects may seem similar (#8 in BPD and #6 and #7 in NPD); however, the emotional aspect of BPD (#6) is not present in NPD. There seems to me to be a split between self-hatred and the instability of self (in BPD), and self-importance and self-love (in NPD). I’m not sure this a gulf that can be bridged sensibly between the two disorders.

Why does it matter? Well, IMO it matters a lot, because the “prescription” that is effective for BPD is not the same prescription that works with NPD (or other variants on the Narcissistic spectrum). NPD is not a chiefly an emotional disorder, and emotional tools that are so effective with BPD will not be effective with someone with NPD. Now, you might say, “My ‘BP’ is diagnosed and he/she is always thinking about his/herself.” That may be true, yet, IMO, this type of “thinking” about oneself is really experiencing overwhelming negative emotions. It is difficult for anyone to think about anyone else when they are in deep emotional pain. As I have said in the past, I have coined (with the help of others) the term IAAHF (it’s all about his/her feelings) to help represent this state to Non-BPs.

Which brings me to my final point: self-diagnosis. It is dangerous to diagnose your loved one with BPD (or any other mental disorder). Only a trained and knowledgeable (and yes, I know, there are too few of these) professional can diagnose a person with any disorder. Assuming on your own that your loved one has BPD can be troubling for the relationship (at best) and damaging to their (and your) mental health (at worst). After reading a self-help book, such as “Stopping Walking on Eggshells” (SWOE), one has to be careful to diagnose someone else with the disorder. Even my book, “When Hope is Not Enough” (WHINE), can be used to “diagnose” your loved one with BPD, but I’d like to dissuade you from doing so. Instead, I would suggest you use the tools in my book (or, for that matter, SWOE) and see if they work. If my tools do not work, I suspect either you haven’t practiced enough (it takes time, believe me, it took me 2 years) or your loved one does not have an emotional disorder. I personally tried what I learned in SWOE for months before I realized that those “tools” were not effective in my life – which is why I bothered to write a book in the first place.

If you are tempted to introduce yourself to a support group with the statement, “I am married to a high-functioning BP…,” I’d suggest you take a step back and see if your loved one has the other signs of an emotional disorder (which BPD is and NPD is not).

149 Comments

Chris76

June 12, 2008 at 6:01 pm

I both agree and disagree with some of the points you have raised. I think the term “high functioning” vs. “low functioning” is more of a reflection of a person’s social functioning–i.e. are they homeless, do they hold down a steady job, are they able to act “normal” in public situations. By those criteria, my wife is definitely a “high functioning” case. She meets 7 of the 9 DSM criteria for BPD, yet nobody outside the home would know that she rages, picks fights, bites me, threatens to stab herself (and me) and had to be sent to the county mental hospital for a 24 hour watch as a result. She can either love me or hate me, but never both at the same time. During the day she holds down a successful career at a large PR firm, is not confrontational or overly emotional, and is considered to be a successful person who “has it together” by her peers and co-worker She has never been sexually promiscuous or had gambling addictions, and has never engaged in self-mutilation. However, she has a pervasive sense of emptiness and is very emotionally labile at home, and she has a very hard time dealing with the stress of day-to-day life and often wishes she could die. She has never felt good about herself and is certainly NOT narcissistic. Everyone who knows her would believe that she is the most gentle, loving, compassionate person in the world; yet only I know the dark side of her personality.

Now, a “low functioning” case would be someone who is the opposite of my wife; living on the streets, unable to hold down a steady career, substance abuse problems, promiscuity, addictions, etc.
Bon Dobbs

June 12, 2008 at 7:13 pm

I understand your points. I could say that my wife is “high functioning” by these standards. However, my main point is that BPs fluctuate between high andlow functioning behavior, depending on their feelings. I expect that your wife (although I don’t know) would avoid situations in which she feel shameful. To tell you the truth I expected more comments like yours. Like I said I can see both points – but again the point I was making is the swing between apparent competence (high functioning) and active passivity (low functioning). I think this happens in the minds (and behavior) of all BPs. Certainly you are free to (and encouraged) to disagree with me.

Thanks for the comment!

Bon
Chris76

June 14, 2008 at 7:22 am

I understand your point about alternation between “high functioning” and “low functioning” behavior, but I go back to my original point … some BPD individuals are able to COMPLETELY modulate their emotional impulsivity in public settings to the point where they do not exhibit ANY “low functioning” behavior. That, of course, doesn’t mean that they don’t feel completely empty inside. However, I think the definition of “high functioning” really has to do with how they are perceived by others around them and how well they can comply to societal norms (i.e. NOT raging against co-workers or their boss). Some BPD individuals seem to have much less control over the ability to modulate their emotional impulses in public settings, and thus are viewed by the general public as unstable, and usually can’t hold down careers for any length of time.

As far as my wife avoiding situations that make her uncomfortable, I do not feel that she purposely limits the scope of her interactions/situations in an attempt to avoid triggers. She wants to quit her job on a daily basis, but she doesn’t. And I will say that her job would be extremely stressful for anyone, let alone a BPD individual. Strangely enough, the thing that probably makes her successful in her career is her compulsive need for organization — very OCPD-ish.

So, I would say that the bottom line in determining “high functioning” vs. “low functioning” is whether the person has the ability to modulate their emotional impulsivity in public settings and adhere to societal expectations for standards of behavior.
Bon Dobbs

June 14, 2008 at 7:09 pm

Chris,

Hi. I don’t think that BPs can COMPLETELY control their emotionally impulsive behavior (and if so, they are doing pretty dang well I’d say). My wife is “high functioning” for the most part, but she can’t completely control her behavior. It might be that the OCPD-ish behavior/disorder contributes towards your wife’s ability to control her impulsive and emotional behavior. I don’t really know.

To tell you the truth, I wrote this post expecting and hoping to have this sort of dialog with other nons (especially those that disagreed with me). I was trying to point out some of the core features of BPD and how they work against high functioning – especially emotional dysregulation, shame and impulsiveness – which IMO are the three “cornerstones” of BPD.

On a side note, I wonder if you’d like to join my Google Group ATSTP? I think your intelligence, insight and wisdom about your wife’s behavior (and clearly you are still with her, so you’re doing something right – haha) might make a nice contribution to the group. So, whether or not you would like to… it’s been a nice “conversation” thus far.

If you’d like you can request membership here:
http://groups.google.com/group/ATSTPGroup

… but I totally understand if you’re too busy or private (although it is a private group) or whatever….

Take good care,

Bon
rho

June 14, 2008 at 9:50 pm

Recently my BF who I have just left decided to diagnose me as having BPD. I have seen several therapists over my life and underwent MMIPs during a custody battle and no one has ever told me that I was anything but normal
That said my BF has tremendous emotional lability and is on both lamictal and welbutrin. He is OK when he is on the meds but if he goes off he becomes manic, and agressive. The reason for the break up was his inability to commit to any long term plans. We have been together for almost 10years and I only came to learn the extent of his emotional problems over the past year.
He had an uncle who was institutionalized, and a first cousin who was incarcerated with a dx of hi functioning BPD. (she attempted to poison her BF).
Is there anything I can say or do. he is very upset about the breakup and seems to be fixated that I engage in “splitting” and am therefore BPD
Chris76

June 15, 2008 at 7:02 am

Hi, thanks for the nice words. I will certainly join the group!

One last thing to say about the “high functioning” / “low functioning” topic… I understand where you are coming from when you talk about the hallmarks of BPD being emotional dysregulation, shame and impulsiveness. That is certainly 100% true. However, at least from my wife’s perspective, the shame aspect has much to do with her determination not to ever be “exposed” as she puts it. She is such a good “life actor” that even some mental health clinicians don’t believe that she has BPD. When she was admitted to the ER as a “5150” (danger to self), the incompetent attending psychiatrist talked to her and literally laughed at her when she told him she had been diagnosed as BPD.

And in my readings on various places on the internet, I have noticed that “life acting” is a common theme among high functioning BPs. Basically, they are putting up an elaborate exterior facade, and can appear to be completely competent to everyone but their immediate family. My mom and sister, had no idea of the issues my wife had before I broke the news to them after the suicide attempt, and were literally shocked when I told them. I’ve heard that “high functioning” BPDs can often be found in positions of great importance such as college professors, nurses, lawyers, etc. They can be very successful at their jobs, and appear to be warm and caring individuals to outsiders (which they are), but when they’re at home with their husbands, wives and kids and the facade comes off, the true BPD behavior is visible (emotional instability, chronic feelings of emptiness, self-hatred, wanting to die, anger, raging, physical violence, splitting, bizarre arguments that last until 4 am, manipulative behavior, etc.)

The bottom line, and I’m sure you will agree with this, is that whether or not a true clinical distinction can be made between “high functioning” and “low functioning” individuals, they all suffer the same internal shame, guilt, pain, and feelings of worthlessness and emptiness.
Bon Dobbs

June 15, 2008 at 12:42 pm

Rho,

Too bad about your BF. It can be so painful to be labeled as something you’re not. Splitting is a very common cognitive distortion and whether or not you actually DO engage in it doesn’t indicate BPD exclusively. I think many people assign blame and create “good and bad” categories for others. Even the non-BP/BP sp;it can be seen as some form of splitting. I don’t know much about the details of your realtionship, so I can’t really give you advice. Good luck to you. It’s so painful to have to deal with someone who will not commit.

Bon
rho

June 16, 2008 at 5:57 pm

is the inability to commit something seen in BPD?
Bon Dobbs

June 16, 2008 at 8:36 pm

It could be, but not isolation. Usually there is a polar opposite dynamic at work – you know, engulfment vs. abandonment. So it will be totally committed one day, you’re evil the next. When abandonment is touched upon, sometimes a BP will do a “I’ll leave you before you leave me” thing. Fear of intimacy and extreme emotional vulnerability can be at play. It’s hard to say whether the inability to commit is BPD or many other mental/emotional disorders. It could be bad past experiences too. Hard or me to know.
Cecile

June 17, 2008 at 3:57 am

Hi,

I haven’t completely read your post as I stopped at:
“I suspect many “high-functioning” BPs do not have BPD at all.”
Have only skimmed through your other comments as well.

But: I’ve been diagnosed with BPD. Full hit on all the DSM-IV criteria, 9 out of 9. By a real professor in these kind of disorders, so I suppose he knows what he’s talking about. My diagnosis contained the following: “Because of her intellect and ability to reflect on her emotions and strong desire to withhold any emotions or actions that could have severe consequences, the patient seems to have already found a way of somewhat dealing with her disorder. With psychotherapy she could develop these and other skills further and have a fruitful and stable life.”
I’ve been my own therapist for ages, but that doesn’t mean I don’t have BPD.
I also have completed two Masters studies, am in a stable, loving (for as far possible with BPD) relationship and have my own company.

Yes, I have been worse. I am doing quite okay now at the moment. But not even lying on the floor and crying for days and planning my escape from this world could have ever stopped me from working and studying. It was the only thing I had.

My reward for choosing work over social contacts: I’m a high-functioning BPD. ;p
Says more about what our society finds important, than about the person with BPD though.
Cecile

June 17, 2008 at 4:02 am

I like Chris76′ comment.

“And in my readings on various places on the internet, I have noticed that “life acting” is a common theme among high functioning BPs. Basically, they are putting up an elaborate exterior facade, and can appear to be completely competent to everyone but their immediate family.”

“The bottom line, and I’m sure you will agree with this, is that whether or not a true clinical distinction can be made between “high functioning” and “low functioning” individuals, they all suffer the same internal shame, guilt, pain, and feelings of worthlessness and emptiness.”

My boyfriend would have said it exactly the same. I am only just starting to open up to people about my shame and problems. It never occurred to me they would be bothered. I mean, why would you care for someone weak? And they are such an easy target to make fun of… Better to pretend everything is perfectly fine.
Mary

June 25, 2008 at 8:42 pm

I am escaping a marriage of severe verbal and emotional abuse. My husband and I were a very clear textbook case, and his warning signs were very typical. Unfortunately, I didn’t realize any of this until after it was too late! After undergoing months and days and hours and hours of yelling, berating, criticism, name calling and worse, I felt like I was losing my mind. The constant fear of what he was going to do next left me with strong mood swings between hope and fear. It is actually common for abuse victims to start questioning their own reality. One night, after he’d been yelling for hours and had removed the door to the room where I was hiding to escape from him, I was ready to kill myself. I was hysterical and crying and disassociating from the yelling. I curled into a ball and started kicking him away from me. I was frantically looking for some way to make it all end, reaching for a bottle of Benadryl or a shaver, whatever it took. Because of that incident, my abuser decided I had BPD and convinced me that I did as well. Afterall, I was having confusing mood swings, anger and suicidal thoughts everyday! At that point in my life, I was meeting the criteria (even though I never had before and don’t now.) I started reading everything I could find, buying Lineham’s DBT books, trying to get into an inpatient program, DBT programs, etc.

He took me to several therapists trying to get a diagnosis and every single one disagreed. I saw a main psychologist for nearly a year, and she kept trying to convince me I didn’t have it. She tried to let me know that I wasn’t any of those things he was berating me about, and kept telling me that it would be okay if I left him. I even checked into the hospital because I thought I was losing it. Finally, a huge team of nurses and psychiatrists and therapists were able to convince me that I didn’t have BPD, I had a crazymaking abusive husband and was experiencing adjustment disorder from the trauma. When he got really out of control and the police had to escort me to a domestic violence center for protection, I finally accepted the truth- I had married a monster and he was killing me emotionally, mentally and physically. I have learned from abusive recovery books and groups that many women get dragged down from successful, strong careers and positions into whimpering crazy women due to severe abuse.

Unfortunately, he never wanted to accept responsibility for his behavior and went to his own therapist saying I had BPD and he was codependent. Because of his self diagnosis that I had BPD, he was able to completely excuse his own abusive behavior and make himself into a martyr. Because he had convinced me, he used that as further “proof” that he was innocent. He read and copied my private recovery journals and workbooks as “proof” that I had BPD. He terrorized me and bullied me in marriage counseling and every therapist we saw (other than the one he went to alone) looked at me with sympathy and let me know that I shouldn’t feel guilty if I had to leave him.

Four months away from him, and I’m still having nightmares about all the things he said and did to me! Still, after getting out of that traumatic situation, my “BPD” symptoms are completely gone and I am recovering to be the person I was before I met him. I am now embarrassed that he was able to drag me down so low and brainwash me for two years of a “relationship.”

Now, when I hear angry spouses making their own diagnoses, I actually feel more sorry for the person who is perhaps being unfairly labeled. BPD is serious and only a professional can make that diagnosis. Sometimes, it is actually the person with BPD who is trying to diagnose a partner with it. I wonder how many cruel spouses are claiming that their partner is BPD just so they have an excuse for themselves and their own behavior.
Sleepless

June 26, 2008 at 11:54 am

Well, my needs for validation and the appropriateness of this topic lead me to post! I am 5 months out of my home, and I’ve been operating on the assumption that my wife is a high-functioning, or borderline-borderline. I too have struggled with this term, because there doesn’t seem to be much in the way of details, and especially when my wife agreed to take the tests and the results came back negative. The psychologists discounted her due to the lack of hits on the 9 markers, instead positing that she might be dealing with IED – Intermittant Explosive Disorder.

The SWOE book made it’s impact on me, though, as if someone had been looking through my window for a decade plus. The psychologists would say that she doesn’t have a lost sense of self, because she scored that she didn’t, but I’m the one that sat up with her, exploring her feelings into the wee hours of the morning, night after night for years, and this after she raged on me all hours of the night. I heard the words coming out of her mouth, I saw the regressive nature of her pose as she was curled up, talking about shame, guilt, self-hate, only to get too close and rebound and blame me and what I wasn’t giving her.

I’m rambling here, but this is the quandry of those of us who’s spouses rage, berate, keep us up for hours on end blaming, screaming (with kids sleeping- doesn’t matter to them), shoving, and then blocking and screaming “Abandoner!!!” when it’s too scary and too much to take and we head for the door or a locked bedroom, bathroom, etc.

Where’s the diagnosis for this? If BPD’s are all cutters, substance abusers, sexaholics, or some combination, then what am I dealing with? When I can’t voice my concerns, no matter how they are couched, no matter how well I appeal, but I am greeted with blame, rage, sarcasm, stabbing words, and physical attacks, I struggle to understand what I’m dealing with.

I’m out now, I miss my kids terribly, I’m struggling with the decision to proceed with the divorce or not, and the religious aspect troubles me. Maybe it doesn’t matter if she’s high-funtioning or not, I’m the only one she does this to, no one knew before and no one will understand or believe me now except my therapist.

Back to the point of the post… sorry,… I know that there were times when she experienced the dysregulation in public, but her response nearly every time was to walk away from me briskly. That was how she dealt with her emotions in public. In private, there were no such actions, if she felt the need, she hurled it at me. On the subject of feelings, she is admittedly someone that doesn’t feel her emotions on a regular basis. She’s admittedly is not body-conscious, unaware of her stress or physical symptoms. She’s a task-oriented person, and I feel like I’ve lived with a roomate for all these years, no real emotional intimacy. I see it now, I see that I’ve wanted it and longed for it, and I was capable of it. I spent a decade plus being blamed for not providing it.

Rage and blame are a scary thing. Being berated all night – while lying in bed, trying to get sleep to go to work in the morning, is not fun. Having someone try to minimize their actions and their catastrophic effects on a relationship, and instead turn the blame on you for being emotionally unavailable, is mind twisting. I finally had to accept her accusation that I was an “Escapist”, and escape. I decided that this crazy behavior was worth escaping from, just like a prison war camp.

This is more catharsis than contribution, I promise to be more attuned to the discussion in the future if you’ll have me back!
Skip

July 2, 2008 at 10:44 am

“The problem with assigning either high-functioning or low-functioning to a person with BPD is that the very nature of the disorder debunks these categories. BPD is chiefly an emotional disorder (with impulse control issues). Emotions are ever-changing, like waves that carry the mind along for the ride. Whether someone is high-functioning or low-functioning at any given time will be subject to their current emotional state.”

===================

This is an interesting discussion – I would like to suggest that “high functioning” is a useful term – especially for non-clinically trained husbands, wives, and parents.

•• First, what does High Functioning Borderline Personality Disorder refer to – what does it mean?

Borderline Personality Disorder (BPD) is a defined as a constellation of 9 possible symptoms of which 5 are required for diagnosis. This begets the often made statement that there are 256 expressions of the disorder.

The problem a lay person has understanding BPD is that most of these 9 criteria are internal thoughts known only to the person with the disorder. So a lay person (and many primary care physicians or older therapists) tend to place too much importance on the most tangible of the 9 criteria. They will rule out BPD, for example, in the absence of #5.

# 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

# 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

# 9. transient, stress-related paranoid ideation or severe dissociative symptoms

Using the 5/9 definition, 1-3 of these criteria might not be present – for example the spouse or child may not be suicidal or self harming and still be affected by BPD.

“High functioning” is just a broad term to define among the 256 constellations of symptoms, those that do not include symptom #5 and some of the other highly dysfunctional symptoms. More here at this bpdFamily.com link: http://www.bpdfamily.com/tools/articles2.htm

•• You say that many “partners” discussed in support communities are not diagnosed for BPD and probably are not BPD at all.

I suspect that this is partially true and partially not. Clearly some of the ‘BPD partners” are falsely labeled and your example is good. But at the same time, it is widely stated in the technical literature that most Borderline Personality Disorder is not diagnosed.

There are a number of reasons for this – such as many clinicians are hesitant to diagnose for insurance reasons, some don’t want to diagnose because it stigmatizes and discourages the patients, and some are too unsure of their knowledge of the disorder to diagnose it. In addition, many borderlines are in denial of the presence of illness and generally don’t present to clinicians (this is true for many mental disorders).

Furthermore, many “difficult” relationship partners are sub-clinical – having significant BPD traits – but not meeting the threshold for diagnosis.

But the most important point is that the same relationship / behavioral tools often apply in these cases. If the tools work, it allows a couple or a family to function better – than it seems to be not a worrisome issue.

•• You mention that their is no mention of High Functioning in the medical literature. That might not be correct…. I make two reference here just as examples.

Joel Paris uses the term. Joel Paris, M.D. is a professor of psychiatry at McGill University in Montreal, Canada a leading opinion leader in the field.

American Journal of Psychiatry 2005; 162:867–875 “… on a 7-point rating of chronic level of personality functioning based loosely on Kernberg’s model of levels of functioning (44) (using four anchors: “psychotic,” “personality disorder,” “substantial problems,” and “high-functioning”), clinicians rated the dysthymic disorder patients”

The medical community, at this early stage in understanding the disorder, has a prioity to help those that self harm, are suicidal, and can’t hold employment.

The support communities are focused further down the continuum of “dysfunctionality” – basically on relationship partners that are reasonably functional but exhibit a lifelong pattern of instable relations – of which the support member is typically in and trying to understand.

I am not a medical professional. I am a member of an active support group for family members of individual with BPD, BPD traits.

Skip
Bon Dobbs

July 2, 2008 at 12:32 pm

Skip,

Thanks for the comment. I specifically posted this post to solicit this kind of discussion. I wanted to point out that INSIDE the disorder is different than it appears OUTSIDE the disorder. What you point out about the 5 of 9 diagnosis code is true – but I think that shows the weakness of the diagnostic guide. No disorder should have 256 configurations IMO. I hope that the APA will change the diagnostic guide, the name of the disorder and the Axis of the disorder next time it issues a DSM. I think the core features of the disorder (of course I’m not a doctor either) are emotional dysregulation, impulsivity and shame. All of the other symptoms IMO arise from these three. Personally, I don’t put much weight in what Kernberg has to say. Although he is well-reknowned in the field, his theories are too abstract and based on Freudian psychoanalytical models. Behavioral-based models have more utility with BPD, in my opinion (and in research, more effective) – DBT, Mentalization, STEPPS and SFT are all derived from CBT and seem to be the most effective treatments for BPD.

My main point in posting this was to debunk the idea that a person with BPD can choose when to act out and when not to. My wife often “white knuckles it” through the day, it is painful and difficult for her – and she could be said to be “high functioning.” I think the classification of “high” vs. “low” creates a false idea that a person with BPD can just behave better whenever they want to – and that it is a choice on the part of the sufferer – that it is just “behaving badly” or spitefully.

Again, thanks for the comment!

Bon
Bon Dobbs

July 2, 2008 at 1:33 pm

Skip,

BTW, the reference to Joel Paris, MD, I suppose is a reference to his website? Actually, the article on his website is written by Valerie Porr (the operator of TARA) about BPD. It is not “scholarly” and in some ways she is criticizing the idea that doctors know enough about the disorder to properly diagnose it.

Here is the quote from Ms. Porr:

“I remember a night when my daughter locked herself in the bathroom after a rage attack. I called the police. She kept the police waiting outside the door for thirty minutes while I escalated to absolutely frantic concern. When she finally emerged, dissociated from her rage, she acted with regal serenity “as if” she were Grace Kelly. The police gave me that “raised eyebrow” look to which I have since become accustomed. It is a look all too familiar to families of people with BPD who feel foolish and embarrassed when authorities arrive to assist with a problem that now seems not to be there. It is “as if…”

If one combines the professional’s attitudes toward people with BPD with the ability of a high functioning person with BPD to act “as if ” – one is having dinner with Boyer and Bergman as the lights dim. The supportive family member is frustrated and confused by the patient’s demonstration of the ability to effectively act out a denial of the illness, while the doctor minimizes or avoids it with dismissal comments like, “She’s just a teenager. She’ll outgrow it…” and the gaslights seem to dim, again. ”

It is on Dr. Joel Paris’ site, but I don’t see anything HE has written with the high functioning label. Ms. Porr, God bless her, is not a clinican.
Randi Kreger

July 2, 2008 at 4:55 pm

Hi there:

Someone just told me about this website, so I came to check it out. What an
interesting discussion about such an important topic.

Before going into the subject, I just want to mention that while Stop
Walking on Eggshells (SWOE) has become the family member “Bible,” it was
never mean to be an authoritative text on BPD. My coauthor and I were
careful to point this out.

In the Introduction on page 7, we wrote:

“The result of our three years of effort [research and writing] is the book
you now hold in your hands. It is not the last word on the subject. It is
only the beginning. We hope our book sparks interest in new research.”

My point is that I think that people SHOULD look at what SWOE puts forward
and ask, “Is this right? Do I agree? Is there another way of looking at
this?” It is though discussions like these that we all learn from one
another.

Now, regarding high and low functioning, researchers have been attempting to
explain why people with BPD present in such dissimilar ways for more than 50
years. Clinicians have developed various subcategories accompanied by all
sorts of theories.

When I was doing a content analysis of the posts from family members on
Welcome to Oz back in 1996 and 1997, what I observed became the basis for
the theory of high and low functioning and acting in and acting out. (By the
way, there are people in the middle. These were never meant to be either
or.)

However, a decade has gone by since Paul Mason and I wrote SWOE. In my new
book, the Essential Family Guide to Borderline Personality Disorder: New
Tips and Techniques to Stop Walking on Eggshells, I developed a more complex
model.

In this model are several criteria–acting in/out and high/low functioning
are two criteria; others include the type of comorbid disorders, willingness
to obtain help, and the impact of the disorder on family members. The two
overlapping categories are now Higher Functioning “Invisible” people with
BPD and Lower Functioning “Conventional” people with BPD.

Hopefully when the book comes out in October, there will be much discussion.
What I am most interested in is not just people disagreeing, but people
coming up with their own theories. I look forward to discussing them here
and elsewhere.

Randi Kreger
BPDCentral.com
Welcome to Oz Community Owner
Stop Walking on Eggshells and the SWOE Workbook
The Essential Family Guide to BPD (October, 2008)
Bon Dobbs

July 2, 2008 at 8:33 pm

Randi,

Hi! Thanks so much for gracing me with your comment! Really, I’m thrilled. I know you’re putting out a new book on a family guide to BPD and I hope it does well; I’m sure it will with your reputation. I also agree that SWOE is not the last word on BPD and Non-BPs. Randi, your book helped me so much in the fall of 2005… however, I found that other things helped me even more… specifically DBT-FST and my experiments with my wife. I wrote my book to share what worked with me and my BP. I DO think there will be lots of discussion about your book in October – my problem is… other than what you have learned from WTO, where is your experience? I have been doing this every day, day in and day out for 20 years. Granted, I have only been aware of BPD for 2 1/2 years – thank in a great part to SWOE! However, what I have tried to do is explain a step-by-step plan of HOW to validate, HOW to insert your feelings, HOW to apply boundaries, etc. Frankly, Randi, if you read my book, I expect that there is a lot f overlap between your methods and mine. I would encourage you to read my book and I’d love to talk about it with you. My major problem with WTO and SWOE is that most people that read that book and are on that list have a BPx… they have no inkling of how to make it work day-to-day with a BP. I have made it work. I’m not reporting a “cure” – which some WTO people report – only a way to make it work effectively. I know you have worked hard on your new book and I expect to buy a copy… I respect your work greatly and think we can help one another.

Let me know.

Kindest Regards,

Bon
Skip

July 2, 2008 at 10:01 pm

Bon,

I understand your point and I appreciate the feedback.

When I read our responses, I can’t help but think we might be talking about two different things.

My use of the term, in a simpliest example, would be to separate BPDs that self harm at some point in their life from those that don’t. One person would could be high functioning – another might be low functioning (self harming). Dr. Young (founder of the Schema Therapy Institute) uses the term this way during this interview:
http://www.gulfbend.org/poc/view_doc.php?type=doc&id=13055&cn=91 I use this reference because you mentioned SFT.

Recognizing these more subtle expressions of the disorder is important, because it is a way to identify and connect these people to all the behavioral tools you sited above. Hopefully this would help some families.

The definition you are contesting, if I understand it, labels different expressions of behavior in the same person… such that they may have had a high functioning day vs a low functioning day. Your point being (if I understand it) that you find this use of the term to be misleading.

I agree that if the term was used this way and then extrapolated to mean “that a person with BPD can just behave better whenever they want to” that would likely lead to a non supportive family environment – which is very important.

I apologize for not being clearer on my reference to Dr. Paris – I posted it below. And I’ll put a big caveat on all of this – I’m just a thankful consumer of the work of the professionals mentioned here – I hope I haven’t over stepped or taken anything of of context in my posts.

The behavioral tools that have evolved from the collective work of these individuals are very useful.

Skippy

PS: The Fall of an Icon: Psychoanalysis and Academic Psychiatry by Joel Paris Toronto: University of Toronto Press, 2005, 225 pp.
Bon Dobbs

July 8, 2008 at 3:34 pm

Skip,

Hi again. My wife is, by this definition, both high- and low-functioning. She is high functioning MOST of the time – she can (or has) kept a job, has repsonisbilities, taken care of children, etc., etc. AND she has self-harmed.

As I said I wrote the posts to promote this kind of discussion. My underlying point is that the “type of” borderline I describe in my book is BOTH high- and low-functioning depending on the current emotional state of the sufferer. The very nature of the disorder (at least as I describe it, which covers – I haven’t done the math and don’t know the distribution likelihood on the 256 combo specturm – I’d say at least 80% of BPD and more like 90% of the hundreds of BPs I’ve met) implies periods of high- and low-functioning. If we accept that BPD is chiefly an emotional regulation disorder (rather than, say, an attachment or object relations issue), it follows that periods of high- and low-functioning would occur.

When you mention the 256 possible configurations of BPD (5 or more of 9 criteria) I wonder if anyone has done a frequency analysis of which criteria are MOST likely and which criteria are least? And where each combination of the criteria fall on a distribution curve? I think it would be interesting, because, although it is theoretically possible to have 256 separate configurations, which occur most often? Someone MUST have done this if the data is available.

I personally have seen MOST of the BPs (and loved ones of Non-BPs) with which I have come into contact having criteria: #1 (fear of abandonment), #2 (unstable interpersonal relationships), #3 (if you include “shame” as identity disturbance, other wise, not so much), #4 (impulsiveness), #6 (emotional dysregulation) and #8 (inappropriate anger, which IMO is on outgrowth of #2 and #6).

So, that’s basically 6 of 9.

Unfortunately, #5 (suicidal gestures and/or self-harm) is all too common as well.

Bon
Border Life

October 19, 2008 at 8:58 pm

Thank you for the interesting post. I’ve enjoyed reading it and the comments, and am happy to see that there will be some guidance in the next SWOE on defining high functioning versus low functioning for people with BPD. I can attest that I have BPD and have had a successful career and close friends with whom I have stable relationships. My wife also has BPD, and is in upper level management and holds a Ph.D. My relationship with my wife was/is not stable. I also suspect that more than a few of my friends have BPD, and one with NPD. These people are well educated and maintain successful careers in academia and business. It seems that what I’ve noticed is that the work performance put in is often so steller, that “quirks”, including bouts of anger, are tolerated. Any anger I had towards my manager was for the most part constrained to displaying anger at home or behind closed office doors, where I ruminated and expressed anger for hours on end. If you think about it, “low functioning” people with BPD do not (typically? tend-to?) self-harm (if that is one of the criteria for low-functioning) directly in front of their manager or loved one, or a group of peers. There are some ways in which impulsive behaviors are under a degree of control.

Note, when angry at my manager, I did not think that most of what my manager did was PERSONAL. For me, I think that was the key in not acting out very impulsively at work. I would have found the anger, and expression of it, justifiable, as I did in my intimate relationships, if I thought that there was deliberate maliciousness directed towards me.

As I told my best friend, I’m a pretty great co-worker and friend. Just do not live-with or marry me.
Ric

December 31, 2008 at 6:28 am

Hi Bon,
Interesting debate. I am in the position of being a mental health professional and having been married to someone with a pd (of some type) for over 25 years. From both perspectives, I believe that diagnosis is a bit of an illusion for these types of condition. Unlike diabetes for instance, there isn’t something you can identify as an illness, treat, and the symptoms become manageable. My partner has characteristics which correspond to at least two forms of pd, bpd and npd. As far as I can work out there is an issue about whether someone’s narcissistic traits are based on indoctrinated over confidence, or whether they are a defence mechanism to massive insecurity, or a combination of both. It is interesting that there is a distinct gender split in the proportion of people diagnosed with each condition too. The point I am coming round too, is that I find Randi Kreger’s model, of high functioning BP very helpful in understanding my partner. She is able to find professional work, and in some circumstances maintain it and do it well. However, she has a track record of jobs ending disastrously through her conflict with colleagues, of major clashes with her own family, and of regularly haranguing me and the kids. Despite this, she keeps up a strong public profile of ‘success’, and I, for better or worse, have colluded in supporting her in this. Sorry I haven’t yet read your book. At present I am ‘self-helped out’. Randi’s book, and ‘Wolf in Sheep’s Clothing’ have both been a great help. Will get to yours when I have worked through some more of the issues.
mark h

April 21, 2009 at 3:23 am

hi there,

i’ve recently come out of a 5 year on-off relationship that was quite frankly, hell. From a very early stage i knew that something was seriously wrong but had no idea what or how to deal with it to the extent that, due to her behaviour, on more than one occasion i would leave her vowing not to go back (now obviously in hindsight the worst thing i could do!). It is only very recently that i’ve come across the term BPD and all it’s inherent “features” and this was only after speaking to a friend in mental health who suggested my ex-girlfriend displayed many of the associated features. I only wish i’d known of this condition/illness 5 years ago!

With regards to the myth of the High-functioning BPD, i would have to disagree as i do think the label/distinction is helpful although I also think that elements of both low and high can co-exist or overlap at different times? My ex successfully held down a job as a midwife (a classic High BPD profession/job?), is highly regarded in her position, owns her own home, financially independent, life and soul of the party, very sociable, always immaculate in her appearance, rarely displayed the rage/emotions in public (or more pertinently to others) that were displayed to me and her children, didn’t self-harm, was not outwardly suicidal etc. However she was prone to alcoholism (her mother was a 20 year alcoholic who recently passed away), has had problems with drug use/abuse, has had periods when she has not been able to cope with life to the extent of staying in bed for days on end, has massive fears of abandonment, emptiness, distrust of loved ones etc and also a tendency to develop unhealthy friendships – with members of both sexes whereby the other party is (mis)lead to think there’s more to the “relationship” than there actually is.

I read somewhere that for the non-bpd it can often feel like you’re living with Jekyll and Hyde – i couldn’t put it any better. To experience even the change in facial expression from seemingly happy to instant rage is truely awful. The swings between moods could be instant and unexplained and when they came on I learned quickly that the best (only) thing to do was to get the hell out of there until she had calmed down, often days later. I realised alcohol was often a trigger, seeming to act as a slow working release of otherwise generally well-hidden emotions but again, even when alcohol was involved rarely would those emotions come out in public, usually in the home only.
mark h

April 21, 2009 at 3:38 am

personally have seen MOST of the BPs (and loved ones of Non-BPs) with which I have come into contact having criteria: #1 (fear of abandonment), #2 (unstable interpersonal relationships), #3 (if you include “shame” as identity disturbance, other wise, not so much), #4 (impulsiveness), #6 (emotional dysregulation) and #8 (inappropriate anger, which IMO is on outgrowth of #2 and #6).

So, that’s basically 6 of 9.

My ex fits the above but I suspect that she also meets the criteria for #9 too…
mark h

April 21, 2009 at 3:51 am

last thing 😉 I have a very good relationship with my ex’s children, a boy of 12 and girl of 7 who come to stay with me often and i’m very worried about the effects on them, particularly the boy who seems to get the brunt of his mums anger/displeasure/frustrations. He’s also very clever and can see already that his mum’s behaviour is somewhat out of the ordinary. I don’t know what (if anything) I can do in terms of helping them.
Lax

June 28, 2009 at 4:34 pm

Hello,

I need a suggestion…
My brother’s wife seems to be Borderline BPD.We are not able to undestand.
Here are the symtoms…
a. Immense rage – sometimes on very small things
b. Blaming others for almost anything.
c. She gives sleepless ness to my brother..keep complaining about someone such as my mother,my wife or something else. Blaming others always and giving small execues.This goes on and on.Same things over and over.
d. She tells him things like you are not a good husband,you dont stand by me..etc.
e. She has become very manipultive,she makes my brother do what she wants otherwise she starts crying ,cursinge etc.
f. She will call continously 7-8 times until my brother picks up the phone.

There is nothing wrong with family membes,all are caring and supportive.But we are not able to undestand her.
I realised her wierednees when she she stayed with us for couple of weeks.She has wiered way of talking,dressing…etc.Its very difficult to have conversation with her.

She has become so manipulative that she doesn’t speak to me and my wife for no apparent serious reasons.Makes up some issues and gives reasons for not speaking with us.

My brother has stopped talking about his wife to us at all.

Not sure what to conclude and how to help.
Markos

July 26, 2009 at 12:04 am

Interesting. I have read through your blog, the comments about the comments, and have come to a conclusion. If you haven’t been it, you can’t know it. You can observe, read about, piece together information, clinically test data, and study the latest brain scans. You can also live with it, try to help another manage their illness, for better or worse, you can have all the best intentions, or just get the hell out….. but, once again, if you haven’t been it, you can’t possible know it.

I am somewhat amused by the many people in the Borderline industry that think they have the nature of the illness figured out. I have read Gunderson, Linehan, and many others. I know DBT, CBT, Mentalism, and most other approaches. I’ve read it all. Bless their hearts, I wish I had read what little was out there 30 years ago. I lived only a few miles from the NIMH, where the BPD research was collected into the diagnosis. And every one of the researchers are partly right. No one model fits all. Each has staked a claim to a certain idea of what the borderline is or isn’t, and at any given time, a BPD can be all or none, bits and pieces or morph into something no one has ever seen. There are as many different presentations as there are people that are afflicted by it.

I should know, I’ve been on both sides. I have been a high-functioning Borderline for my entire adult life, until a year ago. My immune system collapsed under the stress of being me. After a year of getting a handle on the physical issues, I finally ended up in a medical-psychiatrist’s office dealing with depression and wondering if my brain had escaped injury. I went to a nationally recognized teaching hospital. My doctor said I had the most complicated mind he had ever been presented with. Good thing or bad thing? Both, he said, a gift and a curse. Fine then, fix it, or end it. I’m done, no more pain. I went through complete neuro-psychological testing. Very interesting results. Nothing came up on the personality test. Great.

At about the same time, my daughter was in a behavior class at UVa Med and called to say dad, I found you. This is who I grew up with. You have a Borderline Personality Disorder. She sent me the DSM, 9 out of 9 over the years, was fairly conclusive. My psychologist confirmed. But I didn’t fit the profile. I was a very high-functioning borderline, even able to hide it from my friends who were doctors, nurses, and psychologists.

High functioning borderlines tend to find each other. It is not only the typical high IQ that we like to share, it is the hope of sharing our pain. We hope that finally, someone will understand. Unfortunately, as they may understand, they won’t be able to help. Our own self absorption will prevent it. Of course, we blame the other, for not being who we need them to be. I have had tumultuous relationships, each partner, with various degrees of disorder. It was through observing my partners, I could see in them what I could not see in myself. The psyche hides what is just too painful to bear. Having seen enough irrational pain, I came to understand that I shared and identified with all the thoughts and behaviors in my partners, I was simply better at hiding them, even from myself. My acting skills were masterful, manipulation more so.

I had been observing and thinking about this for a long time before the physical crisis, knowing something was very wrong. Comparative logic was convincingly strong, many people did live happy lives. Entering therapy was like pealing the onion with a knife instead of my fingers. I finally had names to go with behaviors. Patterns had explanations. I’d seen it all, felt it all. No pain was off limits as pain was something I was used to. After taking apart layer after layer, bubble after bubble, fear after fear, I can say a peaceful mind is possible. 53 years was more than enough. A wonderful revelation was the hypersensitive brain chemistry getting us into trouble, can then be used for a positive expansion, contrasting the negative contraction into ourselves. It can be done.

Marsha Linehan’s DBT is a wonderful treatment, as far as it goes. Teaching the borderline to think paradoxically is a very necessary skill. Awareness and mindfulness are essentials if a normal response to normal life is ever going to be sustained. The very particular emotional discipline of DBT is equally important, acceptance of what is and the confluence of change, simultaneously. Yet, by itself, the mindfulness of DBT’s moment is only part of the task. If that is where it ends, we become better firemen, but we don’t shut down the furnace. Being mindful of the moments of our past, and why we have come to be who we are is imperative, if anything like a ‘cure’ is going to happen. We must learn to be accountable without judgement. Our thoughts and actions have very real consequences. Fearing our fears goes nowhere. Assuaging our fears is enabling. Facing our fears with compassion is empowering.

Borderlines must have as many tools as possible to participate in their own recovery. High functioning borderlines are intelligent enough to create a theater to live within, with all the bells and whistles, and direct the play continuously. We are also intelligent enough to take it apart. We need to see the reasons why we live on a stage. We need to know what we are dealing with. The reasons have been hidden, as the truth is too painful to bear. Knowing from whence you’ve come is a very powerful tool. If we understand why we have developed the thought processes we have, recognize the life that gives us, we can then see how absurd and self destructive it is to continue thinking the way we do. We can learn to discern perception from reality, and respond instead of react, even under the most stressful situations.

I was told by the first doctor I saw that I had built a intricate spider web to live within. He then said I was the only one who could take it apart. He was right. He also assessed my Type A character quite well, when he said, for me, drugs would only numb my anxiety and slow me down. He was right. I wanted desperately to be fixed, not medicated. I used my formidable anxiety level to motivate and inform me. It would have to be cold turkey, double or nothing, winner take all. The process was hell on wheels, bar none, the most painful thing I could possibly imagine outside of a year in a muddy trench filled with decomposing bodies.

I couldn’t care less if the name was borderline or anything else. If it walks like a duck and talks like a duck, paint it what you wish, its a duck. Anyone with any degree of high or low or combo trays of acting out or in, all play on the same team. The different presentations are each a function of individual nature, nurture, environmental, situational, and interpersonal exposure to variables the afflicted couldn’t control. So, look at it in the face, understand it, and kiss it on the lips. This is who you are at the moment, but not who you have to stay. No, the playing field was never level, so we have to learn how to pick up our knees a lot higher when we run. Not compassionate enough? To the contrary, I ache for anyone who feels they have to live in a disordered mind for a minute longer than they have to. I know how bad that mind wants to feel accepted and loved. I know how desperate the same mind wants to fill the void in their core with a full and easy sense self, complete, peaceful, and unconditionally loved.

On the other side, life is good, sleep is easy, food is digested, the body heals, nothing needs to be analyzed, no one is to blame, and best of all, we can love as we are loved.
Bon Dobbs

July 27, 2009 at 10:02 am

Markos,

Thanks for the long, detailed comment on my post. The entire purpose of the post was to generate this kind of comment, debate and discussion.

You are very right that a person who never experienced the disorder cannot completely understand it. I have said that in various places, including in my books. My effort here and in my other writings is to try and build some sense of understanding for the loved ones of people with BPD and help spur on compassion, skillfulness and respect. I feel too many people dismiss those with BPD as crazy and incurable – neither of which is true.

Thanks again,
Bon
Markos

July 30, 2009 at 10:58 am

Bon,

Sorry about the length, but this is a big topic. I respect your desire to build a body of knowledge and wherewithal for those dealing with Borderlines. Certainly, it is one of the most difficult tasks one can take on.

Regarding the high/low concept, as well as the act in/out, one must know how the borderline mind processes in order to understand the variation in presentation. Borderlines speak a particular language. It will be more or less sophisticated, depending on differing factors, which determine the high/low quality of presentation. If the factors stay relatively consistent, the borderline expression will be consistent. If the variables change, by nature or intensity, the presentation will change. It is like pulling a spider web from different ‘attachment strings.’ Some are more structurally significant than others, yet, each will change the shape of the whole.

The high-functioning borderline has more intellectual and physical resources at his/her disposal, to reinforce the interior and exterior defense. Thus, the expressions can be more subtle. The low functioning does not have the same abilities, so the expression is less sophisticated. Most will never see a high functioning defense. Everyone will see the lower the functioning defense. The difference between the two is not a myth. However, the difference is in the comparative presentation. The core issues are the same, but each need to be approached very differently.

If you approach a high function borderline with low functioning techniques, they will laugh at you. If you deal with a low functioning as a high, they won’t know what you are talking about. This is a very intuitive area. Unfortunately, the borderline universe is so broadly contorted, anyone who hasn’t experienced it within themselves has a limited reference parameter to work from.

To date, little has been written or researched regarding the causation, perceptive motivations, and manifested processes, that together create the borderline universe. Believe me, it is a big dark universe, but only because we have shut out the light. A disordered mind is not a mind without order, it is a disordered order. However dysfunctional, we fully rationalize the world the way we see it; justifying our misery, indulging it, sometimes to our death. We interweave enough reality with our perceptions to convince ourselves of the ‘truth.’ We cannot see that we are simply wrong. And that is where the intrapsychic battleground actually lies.
Bon Dobbs

July 31, 2009 at 9:49 am

Thanks for the comment. I don’t completely agree with everything you’ve said here. I have met 100’s of people with BPD and their families. There are some common aspects between “high functioning” and “low functioning” BP’s. One of the main ones is emotional dysregulation, which I believe is the most common feature of BPD. Emotional techniques work with both categories.
Markos

July 31, 2009 at 1:31 pm

I agree there is much crossover, and many commonalities. But, there is a world of difference between the way you might deal with a low functioning BP who can’t hold a job and an high functioning BP who is a successful investment banker on Wall Street. Though the core issues are the same, the vocabulary, the attitude, the methods of recognizing thought processes within each are totally different. Where emotional dysregulation may be common to each, the low and high, in and out, will perceive it differently in themselves. The emotional techniques must be packaged differently to accommodate the sophistication of the mind you are dealing with. As Randi and Rachel both point out, one size never fits all.

Years ago, I laughed at a friend’s account of her ‘abandonment’ therapy, yet, I was drawn to the abstract, sophisticated thoughts of paradoxical thinking and mindfulness of the Tao. I had to work my way down to the swamp. The low functioning is already there.
Bon Dobbs

July 31, 2009 at 1:53 pm

While one size doesn’t fit all, certain techniques are more successful than others. As I have always said, if you try the things in my book “When Hope is Not Enough” and they don’t work, try something else. If you try the things in Randi’s books and they work, keep using them. I have seen a lot of success with what I have proposed in my book with high and low functioning BPs. When a person is in the middle of a period of emotional dysregulation, I think most categories go out the window.
Markos

July 31, 2009 at 3:17 pm

All quite true. Which means one really must be prepared with all the tools one can have, including the BP him/herself. Categories are really for the general practitioner, or beginning non-bp, who needs a map. But once you are in the landscape, and then the swamp, you’ve got to know how to swim with an intuitive sense of direction.
just me

August 4, 2009 at 11:39 am

hello!

i’m not a doctor and im not as talented with words as all of you, but i just wanted to add my 2 cents.

I have BPD and I am considered to be high-functioning as i have a full-time career that i have won awards for and have been in for years. i am very well respected in my job and community. I get along well with the public and my friends and family for the most part.

I think a big part of being high-functioning for me is all the life experiences i have lived through, as well as being in therapy on and off for 20 years. I have had many different kinds of therapy that has helped me modify my behaviors. in order to survive i have had to learn quickly what is “acceptable” behavior and what isn’t. and to do that i wear many masks, as a lot of borderliners do. no one in my life would ever think i’m BPD because i have learned to hide it so well. not even my husband, or previous therapists, as i was just recently diagnosed BPD after 20 years of only carrying the diagnosis of major depression. i only let certain people see certain parts of me, but never everything… fear of abandonment if they know the real me, right?

my rages are now internal and i dont go off on friends and family anymore, i go off on myself with self-harm when i find time alone. my mood swings are hidden under a mask unless i am alone, or with the 2 people in my life that know most about me. I have faked it my whole life, that is the life i grew-up in, always faking our identity to look perfect to the world. so it comes easy to me, that is all i know.

I have to agree that no one can really understand what goes on in a borderliner’s head, it is just too complex and always changing. Every BPD handles thing differently and you really have to be “there” to understand the depths of it. Over the years my BPD has changed and looked different at different times. i am quick to copy behaviors in the environment im in so i dont stick out, or lose their acceptance. I dont think high-functioning means you can turn it off and on. i just handle it differently depending on where i am and who im with. I am slowly letting my husband see the real me and trying to take off all my masks, but even i have a hard time knowing what/who the real me is.

I dont know if i really have a point, or if this makes any sense, but i just wanted to through my 2 cents in. reading that some people think its not BPD if you can “turn it off and on” sounds like a good theory… but no one really knows what goes on inside our heads when you think we have it “turned off” but for me, its worse all around than when i have it “turned on.” as the poem, “The Mask I Wear” (www.community4me.com/TheMaskIWear.html) says, “dont be fooled by me, dont be fooled by the face i wear for i wear a mask. a thousand masks that im afraid to take off and none of them are me. pretending is an art that’s second nature to me, but dont be fooled…”
Markos

August 7, 2009 at 9:44 am

Oh yes, just me, this is what few understand. And this is why high functioning borderlines are so different, in presentation, from low functioning. I too was so deeply hidden behind all of the positive projection of the false selves, no one would have ever known of the fear and the aloneness.

I probably would have gone on forever if the anxiety I bore inside had not nearly destroyed my immune system. Eventually, the body will have serious somatic responses to the anxiety and something will have to give.
I nearly died from Pernicious Anemia a few years ago, which played a huge role in taking the onion out of the bag, and not being able to hide it in another one. You can’t start pealing if it isn’t in your hand, directly in front of your face. What I am seeing, though, is most of my HF borderline friends are ‘comfortable’ behind their defensive masks. As long as life is fairly ‘even,’ why would anyone go through the hell of opening a tender wound?

And that is why most therapists won’t go near it. Have you read ‘Get Me Out of Here’? Its quite an account of a long road, but someone quite different from you and I. But, I don’t think we have to hit bottom before we can be helped. We have to be talked to differently, as I wrote above. We have to be approached by someone who knows our strategies, and isn’t diverted by the many masks. HF borderlines are so fascinating, so incredibly smart and savvy. Among my friends are highly respected lawyers, investment bankers, a neurologist, an engineer/sculptor/architect, Oracle wiz, NICU nurse, a guy who builds schools in the Middle East, India, and China, and many, many artists of all different media. Who would dare approach anyone like these at the top of their professions? Who would know just how afraid each one is, as their mind swirls in the dark of another sleepless night? You must run rings around your therapists, to have escaped the pealing process for twenty years.

And yet, we so want to be known, accepted, and loved for who we really are. The problem is, we, don’t know who that is either. And we are deathly afraid of find out. But that is the misconception of all Borderlines. That who we really are is something to fear. The sensitivity that needed protection in the first place, is an amazingly wonderful attribute, once it is allowed to exist of its own accord, secure within the true self. Getting there, for me, has been the journey and not just settling for coping strategies. I wanted nothing short of a deep abiding contentment with who I am, without fear or mask; not something I see much in the general public. Arriving there has almost made all the pain worth it. Seeing others get there, would make the years of pain dissolve.

.
Bon Dobbs

August 7, 2009 at 11:06 am

Markos,

Your comment here helps me to illustrate the point that I was making in the original post. The shame and unstable self is IMO common to all people with BPD, regardless of whether they “present themselves” as high- or low-functioning. “The anxiety you bore inside” is exactly the point I was making – that despite appearances, both high- and low-functioning borderlines are suffering deeply INSIDE.

BTW, I read “Get Me Out of Here” several years ago. I thought it was interesting and Rachel reminded me of my own wife. It is rather long, yet it is still quite engaging.

My purpose here is to encourage understanding of the disorder and compassion for people with BPD and thier loved ones alike.

Bon
Markos

August 8, 2009 at 12:47 pm

Understanding and compassion for the disordered and their loved ones is indeed where to be after recognition. And the debate of high and low is indicative of where the industry stands. With all the best intentions, everyone seems to be sig-saging forward, typical of science. The evolution of discovering cause and effect is rarely linear. In the mean time, people are really hurting. I now know that my mother was a borderline, who dealt with her mood swings and emotional dysregulation as best she could. As a result and to her death she lived a compromised life, a best case, make do existence. When I read life accounts posted on your blog and others, it breaks my heart to see the capitulations to the same compromised life.

I recently responded to a friend who sent me some of her incredible writing. She is slowly beginning to see the path, though fearing the unknown beyond her defenses. This is what I wrote back:

I love your piece, I get every word. And yet, I know what you feel so profoundly is an illusion, a fourth dimension your beautiful mind has created to protect you from your void. I have discovered the truth of the void. It too is an illusion, the emptiness. The truth of what we perceive as the void, a spherical black hole, the vastness….. is a clever mirage, that large enough brains with wounded enough psyche’s create; to protect the tenderness within, so we won’t ever approach it………… I painted that void, I feared that void, the damn thing ran my life, and all the while, I had no idea I was painting the veil of Oz.

The borderline thinks the landscape and the swamp painted on the veil is reality. It isn’t. What every borderline needs is a path out of the perceived swamp, with a strong, loving arm to help each one along. Only then we can look back and see it was all a protective illusion.
just me

August 10, 2009 at 11:08 pm

yes, i have read “get me out of here” and even though i am higher functioning than she was, there was a lot in it that hit home for me. i think it took 20 years for me to be diagnosed because 1)the masks 2)moving to different states/new doctors 3)working on the surface issues the whole time, totally unaware of what was/is hiding beneath and 4)i finally found a therapist that is pretty up to date on many issues. throughout the years things like self harm never came up, because i hadnt done it in 10 years… no need to spill the beans if its not an issue at the time.

i too got very sick and needed surgery. my illness was said to cause many of the same symptoms as depression, so i thought this was it, i had found my saving grace… but sadly, it was not. and within the year after surgery i started reverting back to behaviors that i hadnt seen in a good 15-20 years. thats when everything hit the fan and i decided i didnt want to hold the masks up anymore, i needed to find the true me. my current therapist has worked with a lot of borderlines and she knows my strategies, as you put it, she doesnt let me get away with playing games and holding masks up. she doesnt care how smart and savvy i am, or what career im in, she forces me to unpeal my onion. so i agree with you in that most of us HF borderlines do need to be dealt with in a different way, with different language and possibly someone who can out-smart our award winning persona we show the world.

we live a life of pain and emptiness. we are alone in our heads and cant find the way out. we fight so hard against the thing we want most… to show our true self, understand who that is, and be accepted and loved.
Markos

August 11, 2009 at 11:49 pm

I really believe there is a way to speak to HF Borderlines that cuts through the crap, and gets to the heart of the matter. You are right, though, it takes someone who knows what they are dealing with. If you understand the metaphor and symbol, we actually do articulate what is in our heads. Few actually know what they are listening to. Most HF BPD’s are going to have IQ’s in the 140 range and up, so anyone dealing with them better bring more fire power. To be out in front and see whats coming, one must know the landscape. That combined with a BPD who is ready to do the work. Getting really sick helps. We need to have something put a dent in our narcissistic defenses in a meaningful way. Otherwise, we won’t be motivated; we will simply out maneuver whatever comes along. I lived like that for 30 years, a very exciting, very unstable adulthood. Not any more. I’ve traded a large percentage of anxiety driven excitement for the peace I never had. Now I have excitement when I want it, not the constant rush I needed.

Finding the true self is a very interesting endeavor. The psyche hides the abandoned true self from conscious acceptance, because that is what it never had in childhood. It isn’t hidden anywhere nearly as deep as you perceive it is. You already know half of who you are. What makes borderline so tricky is that threads of perception and reality are woven together by our large minds, into the fabric of our lives. So too, is the true and false self. The first therapist I was recommended to said it quite well, I was the one who spun the web I lived in, and only I could take it apart. I took that very seriously, and learned how to deconstruct myself. Curious, that your therapist ‘forces’ you to peal the onion. I believe that is what it takes, a soft heart and a strong arm. No more victimhood. Remember, the void is an illusion. The fear of its perceived emptiness is to keep your conscious mind from finding your true, wounded sense of self. Healing comes through the wounds.

I am writing about my journey, and sharing it with a few BP friends. Each seems to be in a different state of awareness and acceptance of both the realities and the concepts. After a year, a former BP girlfriend, is finally able to admit her issues and has become really aggressive about moving forward. She called me recently from Germany and pleaded with me to share. She used to stonewall anything that took her out of her narcissistic, black and white idealism. And that is what it takes, to want to embrace the real, outside of our heads.

We have to let go of our victimhood, regardless of the identity it gives us. We also have to let go of the power of our indignation. We have to embrace the idea we might just be average if we let go of our pain. The truth is, we will never be average. We will be just as sensitive, just as smart, just as talented, we will be all those things and happy at the same time. What a concept.
Stephanie Price

September 22, 2009 at 9:50 am

Great post as usual Bon! You definitely have a point. In fact, it seems, this coining of the term “high functioning” can actually hinder recovery as it may lead to denial of symptoms and problems caused by those symptoms. In order for a person to change, they must first acknowledge that there is a problem and change is needed. If they feel they are “high functioning”, they may feel no need to change but (according to your post) this is just an illusion of the moment. This post offers great insight, I will be writing about it soon and linking to it for my readers to enjoy as well. Thanks, keep it coming!
Bon Dobbs

September 24, 2009 at 10:11 am

I believe you have hit the nail on the head with the idea of “not having a problem.” I believe that the nature of the relationship has a huge impact on the level of functioning with respect to BPD. The closer the relationship (whether real or imagined) means, to me, the closer that another can come to discovering shame, judging and rejecting someone with BPD. For this reason, a person with BPD might be more apparently competent (in DBT-speak) with others outside a small circle of friends, loved ones and family. The appearance of competence – and thus high functioning – is just that, an appearance, because IMO, the relationship with others outside of the circle carries less risk of rejection and shame-discovery. However, that doesn’t mean the feelings that underpin BPD go away when a person is “white knuckling it” through by moderating behavior. The feelings do not go away even if the behavior is seemingly acceptable.
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September 25, 2009 at 4:57 pm

Is “High Functioning” A Load Of Nonsense? « Spliit: Borderline Personality Disorder (BPD) Lifestyle Blog
Randi Kreger

September 26, 2009 at 6:11 pm

There is a great deal of misunderstanding about high and low functioning, which is why I changed the terms in my new book, The Essential Family Guide to Borderline Personality Disorder: New Tools and Techniques to Stop Walking on Eggshells, to “Conventional,” “Invisible.” and “BPs with Overlapping Characteristics,” which probably describes most people.

There are four dimensions that comprise the three categories:

* Techniques used to deal with emotional pain
* Willingness to seek mental health services
* The type of comorbid disorders
* The level of functioning

The following is directly from the book:

CONVENTIONAL
These are the classic borderline patients who comprise the statistics you read about in chapter 1. Here are some characteristics of lower-functioning conventional BPs:

1. They cope with pain mostly through self-destructive behaviors such as self-injury and suicidality. The term for this is acting in.

2. They acknowledge they have problems and seek help from the mental health system, often desperately. Some are hospitalized for their own safety.

3. They have a difficult time with daily functioning and may even be on government disability. This is called low functioning.

4. If they have overlapping, or co-occurring, disorders, such as an eating disorder or substance abuse, the disorder is sever enough to require intensive professional treatment.

5. Family members’ greatest challenges include finding appropriate treatment, handling crises (especially suicide attempts), feelings of guilt, and the financial burden of treatment. Parents worry about their adult child’s inability to make a stable life for themselves.

Because lower-functioning conventional BPs seek mental health services, unlike the higher-functioning invisible BPs we’ll talk about next, they are subjects of research studies about BPD, including those about treatment.

Invisible BPs
Unlike lower-functioning conventional BPs, higher-functioning invisible BPs have the following characteristics:

1. They strongly disavow having any problems, even tiny ones. Relationship difficulties, they say, are everyone else’s fault. If family members suggest they may have BPD, they almost always accuse the other person of having it instead.

2. They refuse to seek help unless someone threatens to end the relationship. If they do go to counseling, they usually don’t intend to work on their own issues. In couples therapy, their goal is often to convince the therapist that they are being victimized.

3. They cope with their pain by raging outward, blaming and accusing family members for real or imagined problems.

4. They hide their low self-esteem behind a brash, confident pose that masks their inner turmoil. They usually function quite well at work and only display aggressive behavior toward those close to them. Family members say these people bring to mind Dr. Jekyll and Mr. Hyde.

5. If they also have other mental disorders, they’re ones that also allow for high functioning, such as narcissistic personality disorder (NPD).

6. Family members’ greatest challenges include coping with verbal, emotional, and sometimes physical abuse; trying to convince the BP to get treatment; worrying about the effects of BPD behaviors on their children; quietly losing their confidence and self-esteem; and trying—and failing—to set limits. By far, the majority of Welcome to Oz (WTO) members have a borderline partner.

BPs with Overlapping Characteristics:
Many BPs possess characteristics of both lower-functioning conventional BPs and higher-functioning invisible BPs. Author Rachel Reiland (Get Me Out of Here) is typical of a BP with overlapping characteristics. When she insinuated she was going to shoot herself, her psychiatrist admitted her to a psychiatric hospital. Yet she held a job as a full-time mother and was active in church. Although she acted out toward her husband and psychiatrist, she was able to appear non-disordered toward most people outside her family.
……………………………………………..

In Stop Walking on Eggshells, page 49, I wrote, “These are not official, empirically researched categories. Rather, they are a convenient, real-world way of looking at differences.”

So why bother? Because most of my readers have a family member who does not seek treatment and does not engage in self-harm and are not suicidal. If you look back to the categories, you can see that the implications for family members differ greatly.

We don’t know anything at all about people with the required five DSM traits who don’t seek help. We have no studies whatsoever. All we can do is observe. Now, what I wrote is the product of my 12 or so years of observation. That doesn’t make it “right;” you may have observed something completely different. Researchers have published countless ways to subdivide just the Conventional types, how can we all come to one way to describe those who don’t seek treatment?

I look forward to read other people’s suggestions of how to describe the heterogeneity of the disorder, especially those whom we cannot study because they are not within the mental health system.

Randi @BPDCentral.com
Author, “The Essential Family Guide to Borderline Personality Disorder: New Tips and Tools to Stop Walking on Eggshells”
(Available at http://www.BPDCentral.com)
Bon Dobbs

September 28, 2009 at 12:46 pm

Randi,

Thanks so much for taking the time to respond with such detail and insight. I think we have just been trying to puzzle out some of the information/data about our loved ones with BPD. Sometimes categorization is necessary and helpful.

First of all, we DO have data regarding borderlines that do not seek help, thanks to an epidemiological NIAAA study of almost 35,000 adults. The information on that study can be found here: http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm

My original point in writing this “myth of the high functioning borderline” post was to invite conversation and to make clear what I see in the BPD research community and in my experience with 100’s of people with BPD and family members I have met. If we look into the therapeutic models of BPD, especially the two with efficacy, we find something interesting, and something that seems to me to defy true categorization. Many loved ones find it puzzling that their loved one with BPD can act so monstrously toward them and yet act reasonably in the general day-to-day world. The question seems to be: why?

The answer that I will present here comes from two sources: dialectic behavior therapy and mentalization based therapy. In DBT, Linehan indicates that, in additional to dysregulation in various forms (most importantly emotional dysregulation), people with BPD are subject to three dialectic dilemmas. Those are:

– Unrelenting Crisis – Inhibited Experiencing
– Active Passivity – Apparent Competence
– Emotional Vulnerability – Self-Invalidation

I think the idea that “high and low functioning” BPD is a myth can be explained by #2. A person with BPD will (according to Linehan) swing wildly between these different ways of experiencing reality. Until a balance is achieved and the dialectic resolved through synthesis, the likelihood that the same person with BPD will exhibit BOTH polar opposites, depending on the emotional state is high. Thus, one who is “high functioning” (or “invisible”) in one situation (and exhibits “apparent competence”) can easily swing to “low functioning” (or “conventional”) the next. This idea of overlapping characteristics is similar, yet it seems that the view of DBT is that, when untreated, the borderline will swing back and forth, with little or no time spent “in between”. In this case, ALL borderlines are “overlapping, ” just not at the same time.

In the case of MBT, Bateman and Fonagy explain that ineffective borderline behavior springs from what they call “a failure to mentalize”. They have several modes of thinking that can be exhibited when mentalization fails (teleological, pretend and psychic equivalence are the main ones). In their expression, each of these modes cause different types of behavior and thinking. The “failure to mentalize” can happen at any time and seems to triggered mainly through interpersonal interactions. To answer the question of why someone with BPD can function perfectly in the world, yet be a hellion at home, they point to attachment theory. The closer the attachment, the more affect effect and the more likely that mentalization fails with close attachments.

My point with presenting these clinical arguments regarding BPD is that it seems to me that both are highly dependent on the context of the situation, rather than the content of the situation. The context matters. BPD is a self-regulation problem and in certain contexts (especially close interpersonal situations) affect problems occur, based either on a “failure to mentalize” or “a swing between dialectical poles.” Whatever model one uses to describe it, it seems to me that the only consistency is inconsistency. In order for one to effectively interact with someone with BPD, one must IMO continually frame the context of the situation in one’s mind. I don’t believe any category of someone with BPD is 100% useful for this reason.

In other words, it depends.

The nature of mentalization techniques are, for me, fascinating and decidedly helpful, whether I am discussing something with my BP wife or with anyone else in the world. Keeping one’s “mind in mind” and making explicit the implicit desires, thoughts, motivations, feelings and other mental events in the other person is a helpful skill. And a difficult one. Yet, through mentalization, one can see how “it depends” is an important element when talking about BPD. The context of the situation, the nature of the attachment, the physical state of the people involved, etc. all play a role in whether anyone (BP or otherwise) is dysregulated and behaves (or says) something that is decidedly unhelpful in the relationship.

I believe that a person’s behavior and level of functioning all depends on the context of the situation and that categorization is unmindful. It presupposes another person’s behavior and emotional reaction. I can’t tell you how many times in my non-BPD support group (the physical one that I attend) I have heard a loved one say, “Well, if I say that, she will just do this” (or some such formulation). My advice, based on my research into MBT and mentalization, is that one cannot assume another person’s behavior and words when taken out of the context that supports mentalizing. In other words, the behavior and words of any person (and particularly someone with BPD, because of self-regulation deficiencies) is all context-dependent.

Thanks for stopping by!
Bon
Markos

October 5, 2009 at 12:19 am

Bon, I don’t think you’ve known too many very high functioning BPD’s.

We not only ‘appear competent,’ we are competent. If you read ‘just me,’ she told you that no one has known of her issues, not her therapists, not even her husband. I know 20 more HF BPD’s who are smart enough to know what thoughts and behaviors are acceptable to display and what aren’t. We feel the same as all BPD’s, we are simply disciplined and skilled enough to keep it to ourselves. I know four guys who are a lawyer, investment banker, a surgeon, and an educational theorist….. in their 40’s and 50’s……. and a woman who is PHD Geneticist and another who is an MD, Neuro Intensivist……. all at the top of their fields, and NO one knows their issues. They all know how to ‘act’ in both context and content. That is why it takes a physical or logistical breakdown to make us take a look…. and only then, if we can’t rebuild life fast enough.

Randi is right, there is NOTHING about this very special group, because you will rarely see them. And there are many, many more than you could ever imagine. We know how to present ourselves in such a way that no one would even ask a question. But we can spot each other easily, its like a club. And its very sad. The entrenchment is very, very deep, and beautifully, strategically defended.

Your analysis is interesting, but doesn’t get to the real question of WHY. The psycho-dynamic ins and outs and therapeutic models of what precipitates different reactions is a lovely spider web that many love to discuss. But, it still doesn’t get to WHY. Living a compromised life, leaving the web intact, should not be the end game.

Concentrating on manifestations is about management of a controlled disorder. Manifestation, however curious and intellectually stimulating, is not causation. Finding causation and dealing with it, is about creating an ordered mind with no need for ‘management.’ There is an elephant in the room that no one is seeing.
Bon Dobbs

October 5, 2009 at 10:18 am

Markos,

I can always count on you to disagree with me. As for “not knowing too many high functioning BP’s” I have to disagree. I know 100’s of BPs and hundreds more of their families. I participate on a weekly basis in BPD support groups and have for the last 5 years.

As for “apparent competence” that’s Dr. Marsha Linehan’s phrase, not mine. If I were to come up with a phrase it would be “situational competence” – or competence when not triggered. As for people who have the ability to hide their disorder, that’s just sad to me. The idea that one can never allow anyone, not even their life partner, into their inner world is an example of what Bateman and Fonagy call “pretend mode.” That is, a person is pretending “as if” (their words) everything is fine when they carry around a load of psychic pain. My point was that one can’t always know what’s going on implicitly when one merely looks as the explicit.

My wife is an excellent example of a “high functioning” BP. She is intelligent, thoughtful and capable. She received a top degree from a top university. She has a graduate degree. She has worked competently and effectively in various jobs. She is caring and an excellent mother. Except when she’s not. Except when she feels judged or when someone gets too close to her shame. She had a job last year in which she was one of the best sellers and well-respected employees. She got fired at one point and was able to talk her boss into giving her job back. Two months later, she felt judged and disrespected by her boss and she “quit before she got fired again.”

This point is ultimately where I was going with the research into BPD. The research and the clinicians suggest that functioning is situational. That is, it depends. It depends on the relationship at stake (attachment), the context of a situation and whether or not the person with BPD is “triggered” into emotional dysregulation. No one can function “properly” (BPD or no BPD) when emotionally dysregulated. It’s just not possible, because of the nature of emotions. If you read my book “When Hope is Not Enough: a how-to guide to living with and loving someone with BPD” you will understand why. I explain it in great detail, and not just in the context of BPD. Emotions work to protect us from the world (at least “reflexive” emotions, whereas reflective emotions inform us at a different level). Here is a quote from Dr. Paul Ekman’s “Emotions Revealed”: “For a while we are in a refractory state, during which time our thinking cannot incorporate information that does not fit, maintain or justify the emotion that we are feeling.” That is, it is humanly impossible to function in a “wise or rational” way when we are overcome by emotions. That’s anyone. And BPD makes it especially hard because of the DSM criteria:

“Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).”

Sure, people can be diagnosed with BPD without that feature; yet, I think that feature is intricate in BPD. The fact that we have a “5 of 9” diagnostic code tells me more about the problems with the DSM than it does about BPD.

As for WHY, I tried to explain that in my comment per Bateman & Fonagy. Their “why” has to do with attachment and the development of what they call the “alien self”. When attachment to a major life figure (like your mother) fails, one begins to develop an “alien self”. If one goes through life with this alien self doing all the interacting, one is in one of three non-mentalizing modes: teleological, pretend or psychic equivalence. I could certain go on an explain what each one means, but it would take more space than I’d like to use here.

I think some people are better at “hiding” their true self than others. But for me, as I said in my response to Randi, that’s situational. Anyone can come up with exceptions to the general idea of what a person with BPD is like. Most of those exceptions are based on external, observable factors – like Randi’s. My analysis takes into consideration the internal factors.

You said in your initial comment on this blog: “it is the hope of sharing our pain. We hope that finally, someone will understand. Unfortunately, as they may understand, they won’t be able to help. Our own self absorption will prevent it” and then you go on to explain/defend the concept of “high functioning” borderlines. My comment is this then: just because you function/behave “properly” in society (and in relationships in some cases) does that negate the pain? You seem to indicate a desire to share your psychic pain with others. If you can’t, does that make you “high functioning”? To me, it seems to make you “pretending your way through life” because you can’t be authentic with other people because of the inability to share your inner pain.

This is why I said that the idea of even one’s partner in life not knowing the “true you” is sad. Not being able to make a true connection (possibly because of the rejection sensitivity – i.e. “if he knew what I’m REALLY like, he’d hate me”) in life seems tragic to me.

You say that this group is “very special” with which you seem to be distancing yourself (and the members of this group) from the “other” borderlines. Rather than categorizing people with the disorder I like to look at what they have in common. IMO that’s emotional dysregulation (which is situational), impulse control (which is situational and based on dysregulation) and shame.

Bon
Markos

October 5, 2009 at 2:03 pm

Bon, its not that we are in disagreement and I am questioning your experience or knowledge. They are both quite substantial. What I suggested way back when was, you can’t know what you don’t know, and if you haven’t been one, you can’t know what it is. You agreed. You can certainly read, observe, and study to ascertain what it LOOKS like, and how it manifests. But that is not WHAT it is, or WHY it is. And unfortunately, because of the dysregulation you spoke of, most borderlines don’t and can’t know either. So, most everyone is relegated to management of the disorder. Sorry, not good enough. Any web at all is still an unhappy place to live, period.

The ability to live unconnected to the true self is not only sad, it is tragic. The guy who wrote ‘Border Life,’ last year lays it out, don’t live with him and don’t marry him. Believe me, knowing the difference for a short while, relative to my 53 years in the prison of BP, gives me great regret for a life I couldn’t have known. But now I do know, and I understand, and live VERY differently. I feel for your wife, continuing to suffer. I empathized with a leader of a borderline support group recently. He and his BP wife have been through 15 years of BPD, 5 years diagnosed, and they still deal with her meltdowns and manipulative communication. They have been through DBT, some MBT, and so forth….. and still suffer. Sorry, not good enough. WHY?

We have all been dancing around the elephant in the room, and we keep getting trampled or pinned against the walls. Problem is, no one can figure out how the elephant actually got in the room, or how to remove it. The freedom of using the entire floor space, with no elephants is something few ever know, borderlines or otherwise, but especially borderlines.

We find each other to share our pain, thinking the deep connection will be the answer. It isn’t. Simply identifying with the pain does little but to comfort temporarily…. ie…. misery loving company. We end up blaming the other for sharing but not removing the agony, and having a dependence on whatever comfort. Comfort itself is not the answer. It ends up being enabling. That is why Marsha uses the dialectic of comfort and challenge. Connecting to our true self is the answer, the question is how?

That is what I am writing about, the very basic causation everyone seems to have missed. My therapist begged me not to move on until I write about it, I agreed it is very important. I know it, I’ve been it, I’ve walked away from it, lived to talk about it, and empathize directly with those still there. Victimhood is gone, I want no sympathy or praise. So, from the other side, I’m getting underneath the manifestations to the whys and wherefores creating the nitty gritty, thorny, sticky swamp we get stuck in and can’t get out of. There IS a ticket to freedom, and it’s a tough road. No Polly Anna, no rose colored glasses. But so worth every painful step, as the load gets lighter.

I actually agree with most everything you’ve said. But the high through low distinction is like different forms of cancer, that have to be treated very differently. The one who cuts or purges or who has risky sex, whom I’ve known well, and the HF who drives a $200,000 Porche through a construction site at 150 mph successfully or climbs rocks with no ropes, both have a cancer with a very different presentation and treatment. The ‘club’ distances themselves from the ‘others’ and you have to reach them where they are. They won’t see anything in common with the ‘others,’ and dismiss you. Their deception is nearly complete. Unless you are one, and then you know the language.

Thank you for an interesting and intelligent discussion.

But the point is to live, dance, and sleep very well, in the room WITHOUT the elephant…….
Bon Dobbs

October 5, 2009 at 2:52 pm

Hey, welcome back again!

I didn’t mean to sound defensive – sorry if I did.

I want to ask a couple of questions and make a couple of statements. When you say WHY, are you looking for causes? Or reasons some get better and some don’t? Or both?

As for some getting better and some don’t, I think it comes down to whether a person with BPD is willing to expose the real self and work on it. Shame often prevents that. The MBT people would say it is because of a continued “failure to mentalize” and a persistence of “pretend mode” – that a person in that situation (whatever the disorder) can “pretend” their way through therapy. Someone who is highly intelligent can still around and conceptually “get” therapy, but never “feel” therapy. That leads me to another question: have you ever heard of Dr. Eugene Gendlin? He was a student of Rogers and has technique called “Focusing” that he reports can help people “feel” therapy, rather than just understand it conceptually.

I think in order for a person to get better, they have to expose their true self and to actually “feel” therapy deep down. Otherwise a person will go around and around in circles.

On a side note: Bateman’s data shows that MBT doesn’t truly take hold until about 12-18 months of therapy. So, I guess it takes a commitment as well. My experience with people with BPD is that they can burn through therapists rather quickly.
Markos

October 6, 2009 at 9:30 am

No worry, Bon, I enjoy a good debate.

The WHY I refer to are the many variables that conspire in such a way that make a borderline response inevitable to a certain brain chemistry. There is a lot of crossover cause and effect creating the beast. But there is also a very consistent pattern that I have yet to see proven wrong.

I’ve gone to the heart of the matter in order to understand exactly why I thought the way I did; what were the origins of certain beliefs that manifested themselves in a particular pervasive perspective. Identifying and understanding the process of patterned perception vs an acceptance of reality, allows one to discern ordered thoughts from disordered ones. There is a procedure for doing this, and quite obviously, at the very core of recovery. Without it, one doesn’t get very far. But, it takes tremendous discipline and a determination to be well.

A determination to be well is the key to getting better, but the road is a bit different for the high/low distinction. LF BP’s are very honest about their pain but lack access to the IQ needed, to do much of the work. Much like the emotional child they are, they will have to be led. HF have the IQ but are deeply defended with multiple layers. They will have to be convinced there is a way to be their productive ‘self’ AND be happy. Either way, both take discipline and determination, AFTER and WITH an admission there is something very fundamentally wrong.

All the theories, like Gendlin’s, about the relative nature of thought send one into a beautifully layered universe much like the layers of a transparent painting…… and similar to how the HF BP thinks. Thought derivation and relativism are about the manifested mind, the thick of the spider web. You can get very caught up in that space, which is where most psychiatrists end up. Remember, we are talking about an elephant. Borderline causation includes the web, but indirectly. The very complicated indirect origins are what I am writing about.

Who gets better and who does not depends on wanting to be well, and going cold turkey off their addiction to victimhood, as a first step to getting there. BP’s can easily see, and usually express, we are different. We see that others can be happy and usually envy/deride their ability to accept life at a superficial level, because we feel so deeply. The desire to be well must ultimately override anything else. Then it is a question of having the proper guidance, self reliant if possible or otherwise.

The reason the illness exists is to hide the true self. The concept of exposing it, as if it is flipping a switch, is virtually impossible for a borderline. Recovery is about the process of allowing that to happen. The time frame depends on how the variables of the process line up, or don’t, and if the BP keeps their own feet to the fire. Most therapists have little idea of how to deal with a borderline mind, and that is why the personal commitment to becoming well is so important.

Partners can help, but that is a very tricky relationship, moving in two directions at once….. a dynamic I know very, very well.
Bon Dobbs

October 6, 2009 at 9:56 am

Markos,

You said, “Partners can help, but that is a very tricky relationship, moving in two directions at once…” My point (of this site and all the research I’ve done on BPD) is to encourage partners and other family members to create an environment that is safe and allows the person with BPD to express their feelings without the fear of punishment and invalidation. If someone is continuously emotionally invalidated (the effect of which I think most “Non-BP” tools/suggestions have), then shame develops. The NATURAL reaction to shame is to hide it. Here is a quote from Marsha Linehan that use in “When Hope is Not Enough”:

[The] effect of an invalidating environment, especially when basic emotions such as fear, anger, and sadness are invalidated, is that a person in such an environment does not learn when to trust her own emotional responses as valid reflections of individual and situational events. Thus, she is unable to validate and trust herself… If communication of negative emotions is punished, as it often is in invalidating environment, then a response of shame follows experiencing the intense emotion in the first place and expressing it publicly in the second.

The inability to reveal one’s true self grows out of that shame response IMO. When a person with BPD “fires” a therapist, it most often occurs (again IMO) when that shame is approached and the distress of discovery becomes intolerable. Since this shame response is natural, it applies to anyone with shame (with which I believe ALL BPs are “endowed” for whatever reason).

As far as “who gets better,” Bateman and Fonagy would say that the BPs that get better are those that can mentalize effectively. Mentalizing allows anyone to “truly feel” and internalize one’s own (and others’) mental states including motivations, desires, emotions, cognitions and other mental processes. While DBT is behavioral (like “training”) MBT is mental and seeks to modify the person’s thoughts at the BEGINNING of the reaction-chain. DBT uses “behavioral chain analysis” to redirect the ineffective choice. MBT uses generating alternative perspectives to redirect the choice itself.

I believe that intellectual analysis of the healing process will get us no where. I think that one has to learn to self-validate and self-soothe in order to quell the emotional pain. No amount of thinking about it will function to internalize these beliefs and skills. I agree that the “illness exists to hide the true self” (and others do as well – like NPD), yet one feature of BPD that seems to be universal is emotional dysregulation. Getting control over one’s emotional reactions is difficult, and having a safe place in which to express these reactions is essential. That is why I encourage family members to learn and master emotional skills.

I have found that, for my long-time list members (and for me), the SWOE approach is just not effective. I tried the SWOE approach 4 years ago when I first started to try to do something about my wife’s behavior. It worked at first, but it ultimately made things much worse in our relationship and in her behavior. Once I changed my approach to the one I present in “When Hope is Not Enough” things got far better, my relationship got closer, and my wife’s behavior moderated. I have reports of the same results from numerous people on the ATSTP email list.

Bon

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