Borderline Personality Disorder (BPD) is a severe, chronic, disabling, and potentially lethal psychiatric condition. It is often characterized by pervasive feelings of emptiness that, in turn, provoke reckless and impulsive behaviors aimed at filling this internal void. Individuals who suffer from this disorder have extreme and long standing instability in their emotional lives, as well as in their behavior and self-image. This is a relatively common psychiatric disorder affecting 2% of the general population, however a staggering 75% of BPD individuals are women. Without treatment and support, most BPD individuals are unable to achieve sustainable recovery. Women, in particular, who suffer from BPD require gender responsive treatment that honors the unique needs and complex experiences of this population.
The instability of emotion, behavior, and self-image characteristic of BPD have devastating and sometimes deadly consequences. Individuals with BPD have repeated and frequent difficulties in their relationships and work lives, often experiencing alternating extremes of anger, depression, and emptiness. The borderline person tends to view past and current relationships as characterized by hostility and experiences pervasive social dysfunction and attachment disturbances. Quite frequently they have suffered from serious trauma including sexual abuse, physical violence, neglect, and psychological abuse.
To be borderline is to have little sense of identity. At its extreme it may mean having to turn to others for cues in order to know when to eat or drink, work or rest, or even laugh or cry. It may mean intensely embracing a person, idea, or thing one day and having no use for it at all the next. Descriptions of themselves often tend to be confusing, conflicting, vague, or unidimensional, lacking depth and feeling. They frequently define themselves in terms of how others see them. For example, their interests, values, mode of dress, and mannerisms may shift as the nature of their relationships change.
This discontinuity is further magnified by an accompanying fragmentation of emotion. Borderline individuals may alternate between being flooded with emotion and being numb to all feeling. In addition, whatever feeling-state predominates at the moment seems to last forever, and the BPD individual can scarcely recall ever feeling differently.
When applied to relationships, this same fragmentation of emotion and identity causes BPD individuals to view their relationships with an intensely black and white quality of feelings. This means that the borderline may experience their last encounter with someone as characterizing the entirety of that relationship. For example, if they parted on angry terms, then the BPD individual might only recall the other person as a heartless villain, wishing bitterly for revenge. Borderline individuals also tend to imagine themselves as deliberately persecuted by those who have merely let them down, placing themselves in a constant state of victimhood.
Complicating this fragmentation of relationships is the likelihood that the borderline’s sense of personal value depends entirely upon the current state of their relationships. When borderline individuals lose a relationship they often lose their inner sense of value that accompanied it. Since abandonment brings with it emptiness, it is avoided at all costs. These defects in identity and self-structure leave borderline individuals with a chronic and overwhelming sense of anxiety or dread and contribute to problems in self-regulation, self-control, self-soothing, low self-esteem, and a sense of personal inadequacy.
Typically, borderline individuals ward off their inner turmoil and unstable self-concepts through compulsive activity and self destructive behavior. This seems to reassure some borderline individuals that they are alive and have feelings. All too frequently, 69% to 75% of individuals with BPD resort to self-destructive behaviors such as self-mutilation, alcohol and drug use, behavioral addictions, serious over or under eating, and suicidal acts to escape from their emotional turmoil or to end dissociation. Often these behaviors serve as futile attempts to fill an internal vacancy, to satisfy a chronic and insatiable hunger.
As noted, a disproportionate percentage of individuals within the population of diagnosed BPD patients are women. There are a variety of cultural, social, and gender related factors that place women at greater risk for receiving a diagnosis of BPD. Violence, trauma, abuse, sexual assault, self esteem, gender specific socialization, discrimination, conflicting social expectations, lack of resources, combined with environmental, biological, psychological, and genetic risk factors are a few of many explanations for the tragic overrepresentation of women among those diagnosed with BPD.
For women with Borderline Personality Disorder, they must cope with a galaxy of feeling that surrounds female socialization and the blend of longing, need, sorrow, and constraint that underlies it. The BPD individual’s yearning for others and her fragmented identity may be intensified by her awareness of its depth and the volume of need it inspires when compared to societal norms often based upon solely male experiences. These women must struggle for ways to cope with being too full of emotion, too hungry, too needy, and with the compulsion to release those feelings while also punishing the self for having them in the first place.
Gender expectations and aspects of female socialization do not make it easy to find available options, possible ways to cope and to express how empty and hungry and fearful these women feel. Many turn to drugs, alcohol, and countless other behavioral addictions in an attempt to find reprieve. For the self-mutilator suffering from BPD, she may cut to make the pain at her center visible, lacking any socially acceptable methods for release. The anorexic starves to make manifest her hunger and vulnerability.
For women with BPD, struggling to cope with the effects of trauma or substance use, a hostile environment, a rapidly dissolving sense of identity, or conflicting social expectations, this can be devastating and, in some cases, next to impossible without long term comprehensive treatment and support. Many BPD women, without help, continue to blame and hurt themselves, remain speechless, or engage, instead, in a pantomime of sorrow and chronic self destruction, an act that can be seen in everything she does if viewed through the right lens. Caroline Knapp, author of Drinking: A Love Story and Appetite, reflects on this very phenomenon with poignant insight,
“Women wanting to eat and slapping themselves for giving in. Teenage girls mastering the art of negative self-scrutiny. A skeletal body forcing itself to run and run. An arm with more scars on it than you can count. This is endlessly sad, this steady, quiet pummeling of the self, women borne along on a river of unwept tears….Way beneath these sensations is an ancient, aching emptiness, a gaping hole so vast you think it could kill you, a longing for comfort…a desperate, driving sadness that comes from feeling unloved, the longing it evokes to be fixed, to be held and needed and valued, to be proven lovable at last.”
The cluster of symptoms that make up the complex and enigmatic diagnosis that is Borderline Personality Disorder are nothing more than an expression of a deeper, voiceless, inarticulate, and pervasive hunger. It is the cavernous void that drives countless women in to the depths of addiction, obscurity, self annihiliation, and untimely death. And yet beneath these symptomatic expressions of need exists a uniquely human (though not uncommon) longing to discover that she is in fact whole and valued…and a fragile hope that through the process of healing she can, at last, be filled.
