Chapter III Recipe For Agony

The Why: The Making Of Borderline Personality Disorder

Writer’s Reflection: The Rabbis tell us that when a tzaddik is shown what their yetzer hara looks like, it will appear as a gigantic mountain of Everest proportions. The tzaddik will exclaim, “how did I ever win in my war with such a behemoth?!”. The rasha is also shown his yetzer hara. To him it will appear as a small, inconsequential mound of dirt. The rasha will exclaim, “Oy!!! Why could I not conquer such a puny adversary”. The baalay Mussar explain that whereas the rasha is overwhelmed by the enormity of the task, the tzaddik goes forward one step at a time. The rasha’s point of view leaves him so immobilized that even a mound of dirt is too much. The tzaddik’s approach allows him to climb even the mighty Everest.

When I educate patients, families, and lay people about the ‘ingredients’ of borderline personality disorder, I always share the deep words of the sainted Rabbis with them. My wish is to reassure everyone that despite the seemingly overwhelming deficits and factors that cause so much suffering there is hope for healing. This hope is grounded in the reality that if, like the tzaddik, we focus on putting one foot in front of the other we can scale mountains.


Is it brain chemicals?
Is it bad parenting?
Is it society’s fault?

The most often question asked about borderline personality disorder is what causes it. And it’s good a question. After all, if we knew the cause, we could take steps to prevent it. By understanding the causes, we can devise strategies to lessen the symptoms.

The fact of the matter however is that borderline personality disorder is not caused by one thing any more than cancer or asthma is caused by only one thing. Borderline personality disorder is the end point of a group of converging vulnerabilities. These vulnerabilities include family tensions, psychological predispositions, neurological sensitivities, social gaps, genetics, and life experiences. Like some sort of horrible recipe, only when brought together does one end up with the pain and agony of borderline.

Throughout the psychological literature, scientists refer to deficits or vulnerabilities that lay the groundwork for the formation of borderline. Taken separately, each of these deficits could be quite disabling. When two or three of more factors come together though a devastating synergy is created. The result is often borderline personality disorder. In order to better understand this horrible recipe, let’s consider each of these vulnerabilities separately:

Neurological Deficits
Since borderline personality disorder is considered a psychiatric disorder, few of us consider the fact that there are also physical dimensions to it as well. Indeed, without adequately considering these physical qualities, all of the well intentioned psychological and psychiatric interventions will have little or not effect. Scientists however have long noticed that people with borderline personality disorder have characteristic somatic attributes. Brain and nervous system irregularities are the most documented of these somatic attributes.

Scientific literature speaks of two types of such irregularities. The first kind involves subtle, minor deviations in the frontal lobe region of the brain. This region is one of the systems that closely evaluate responses to the demands of daily living. Even slight, minimal damage to this region can result in distortions in thinking such as inflexibility and impulsive decision making.

The second type of neurological irregularity frequently discussed in scientific literature focuses on the limbic system in the brain. The limbic system is one of the brain systems in charge of the control of emotions. Specifically, it is tasked with modulating the intensity of feelings. Researchers have found that many individuals with borderline personality disorder have limbic systems that are limited in their ability to calm raging feelings.

The consequence of these seemingly trivial brain and neurological deficits can be devastating sensory hypersensitivity that begin in infancy. As the baby grows into childhood, adolescence, and adulthood, this sensitivity results in an individual who is easily overwhelmed by even changes. Because of this reactivity they often develop strategies of avoidance so that the ‘apple cart’ so to speak is not upset. Parents, friends, and teachers usually support these avoidant strategies out of sympathy for the distress that would otherwise occur.

Such excessive neurological reactivity can easily set the stage for adjustment difficulties in adulthood. While avoidant strategies may be indulged by parents during childhood, it is much harder to cover up such sensitivity in adulthood. Roommates, bosses, spouses, and teachers will have far less tolerance for sensory avoidance. As a result, the young adult may choose either to remain at home or to make choices that serve to protect them from sensory overload but come with “negative side effects”. Examples include self mutilation, addictions, and involvement with destructive individuals.

So Tachlis, what can be done about these neurological deficits? Isn’t one’s neurological system and brain hard wired? What kind of positive changes can be reasonably expected if biology is so stacked in favor of borderline personality disorder?

The answer to these questions is both sobering and hopeful. Indeed, the biology of many individuals with borderline does make living in peace and in joy more difficult. On the other hand the miraculous complexity of the human mind and nervous system have many ‘back up systems’ that permit us to live, learn, and grow even when one or two parts are impaired.

Furthermore, neuroscientists continue to discover the elasticity of the brain. In other words the notion that are minds are fixed and hardened is simply not true. We know now that given the right approach even the most damaged mind can grow again. Effective treatment for borderline personality disorder such as dialectical behavioral therapy offers many strategies for taming these neurological irregularities.

Family Related Deficits
Few aspects of borderline personality disorder have been as hotly debated as the influence of family. On one extreme are those theorists who insist that the parents and family life are the sole contributing factors to the development of the disorder. On the other extreme are those who say that family has nothing to do with the borderline. Biology, social forces, and individual psychology are the real culprits according to this view.

Like every other aspect of borderline personality disorder, it is most likely that the truth lies somewhere in between these extremes. For some adults with borderline personality disorder family dysfunction in the form of child abuse, neglect, and abandonment have a great deal to do with the evolution of their disorder. For others however factors unrelated to the family are clearly to blame. In fact, they may come from wonderfully warm, high functioning families.

Instead of focusing on specific actions of parents as the cause of borderline symptomology, contemporary researchers speak of deficit of validation in the parent-child environment. Validation refers to the unconditional acceptance of someone else’s feelings, thoughts, needs, and experiences. All children have a sense of self that is profoundly dependent on their parents. In a psychological sense, children know only what they are told by their parents. Any feeling, thought, event, or opinion that is experienced by the child is not fully accepted by the child unless his or her parent validates it.

In the absence of a parent’s validation the child remains confused as to whether he really feels or thinks the way he does. When such validation is consistently missing the child may very well live with a great deal of confusion about his or her feelings, wants, dislikes and needs. This gap in validation is in fact responsible for the chronic feelings of identity confusion and emptiness that are experienced by the adult with borderline personality disorder.

One thing is clear however: a mind set, often supported by even the most well meaning professional, that locks the patient in a blaming, fault-finding, vengeful relationship with his or her family is almost always counterproductive. Blaming is always self destructive because it focuses our attention away from where it is most needed: taking responsibility for ourselves, our lives, and our own sanity.

So instead of blaming, an attitude of personal responsibility is the way to go. Adults with borderline personality disorder have legitimate needs, just like everybody else. They need respect. They need others to believe in them, their efforts, and their dreams. Most importantly, they must learn to understand and respect their feelings and their needs. Because they need these experiences like a fish needs water, they are responsible to see to it that they get them. Much of the work of effective psychotherapy for borderline personality disorder is helping the patient get their legitimate needs met in their relationships.

Learning Disability Related Factors
It often comes as a surprise that learning disabilities are a significant factor in the development of borderline personality disorder. Neuroscientists however continue to discover the influence that learning disabilities have over mental heath and contentment.

The two most well understood learning disabilities that influence the development of borderline are inability to generalize and poor ability to problem solve. When scientists speak of the ability to generalize, they are referring to the individual’s ability to use skills that are effective in one setting in a different one. A common example is a woman who can easily handle the complex stresses of the workplace. Home life however is a different story. Despite its similarities to work, she is overwhelmed by her children’s many demands. She is unable to take the skills that she uses so well at work and deploy them at home.

Deficits in problem solving abilities are also common to individuals with borderline personality disorder. Problem solving refers to a group of strategies that are used to choose the best course of action when one must choose between two or more competing demands. A common example is when a yeshiva bochur must decide whether to study one chavrusa or another. One chavrusa is a close friend. The other chavrusa is quite gifted. Who should he learn with? What if his friend’s feelings will be hurt? A good set of problem solving skills are necessary to navigate this difficult situation.

Such learning difficulties compromise the individual’s success in so many different ways. It is not hard to understand that learning disabilities undermine school success which leads to further difficulties. But more than the impact on learning is the impact on social adjustment. Poor ability to generalize knowledge and to solve problems puts one at great disadvantage.

Effective treatment for psychotherapy must therefore address these and other learning disabilities. Dialectical behavioral therapy for instance has components devoted to teaching patients how to generalize and to problem solve.

Trauma Factors
Psychological trauma among individuals with borderline personality is quite common. Researchers claim that more than sixty percent of individuals with borderline have experienced significant psychological trauma. Many of these people also have post traumatic stress disorder.

Psychological trauma traditionally refers to exposure to an event in which the person was afraid for his or her life. In the last twenty years, as deeper understanding of how we handle traumatic events, scientists have begun to claim that even non life threatening traumatic events that are not life threatening can have the same effect. This is especially the case when the traumatic events occur again and again. Common examples of such events are frequent family arguments, family illness, and living in violent, unstable environments.

While these may not be as seemingly traumatic as being in a near fatal car crash, these events have create a cumulative trauma. Such traumatization reduces the child to focus on basic survival. School and friends become much less important than getting the most simple physical needs met. They have no one to bond with, to talk with, no one to find loving reassurance, rachmana litzlan. And because the child is preoccupied with basic survival, he or she misses out on all the other activities that he or she would otherwise be involved with.

On a deeper level however the damage goes deeper than a lost childhood. Trauma profoundly reshapes the brain and nervous system. Each traumatic event, even those seemingly minor, releases all of the stress hormones associated with the fight or flight response. After so many activations, the nervous system gets stuck in an activated state.

A common consequence of such a state is a high degree of physiological reactivity. They are easily enraged since there nervous system are already Furthermore, it becomes extremely hard for such traumatized individuals to relax their bodies. Unfortunately, drugs, alcohol, and addictive behaviors are often turned to because of their seeming ability to calm these chronically terrified people. In addition, due to their state of chronic stress, these people may have a host of physical illnesses and weaknesses.

Because of the high prevalence of post traumatic stress disorder among individuals with borderline personality disorder, effective psychotherapy includes components to address trauma related symptoms. Aside from physiological stress activation, patients may also experience intrusive flash back memories that may be quite disabling. Techniques such as eye movement desensitization and reprogramming, exposure therapy, and various body-centered techniques can help patients regain physiological peace and reduce psychological distress.

Psychological Deficits
The psychological factors of borderline personality disorder are discussed throughout the psychological literature. There are in fact many theories that attempt to explain how this personality disorder comes to be. Some theories have been rejected by scientists as lacking validity. Others theories are still debated and studied.

Despite this vast debate about psychological causes, one universally accepted psychological factor has been advanced by cognitive therapists, Aaron Beck and Albert Ellis. In their view the strongest cause for borderline is a cognitive bias known as dichotomous thinking. Simply put, people with borderline personality disorder automatically process the events in their lives as either wonderful or absolutely horrible.

The result of such “either-or” thinking is to respond to life’s ups and downs with exaggerated joy or exaggerated misery and anger. Because of this inability to question their black and white assessments, people with borderline cannot take effective action to solve problems and make their lives better. Their dichotomous thinking forces them into passivity, despair, or aggressive acting out.

A second psychological factor in the development of borderline personality disorder focuses on emotional memory. Every single event that we experience is contained within our memory. The people who love us, our favorite foods, music, names of people that we have met, and a myriad of other data are stored within the memory’s recesses.

Just as important as these facts are the emotions associated with them. A parent who looks at a photo of his child, automatically feels love and tenderness for that child. A child, having a rough day in school, recalls the safety of her bedroom, easily feels a sense of peace. These are manifestations of the emotional memory. In both cases the positive feelings serve to blunt any negative feelings that are experienced at the same time.

Psychologists have found that individuals with borderline personality disorder lack emotional memory. They have cannot summon up feelings that would counter their current feelings of distress. Without these warm, fuzzy memories, people with borderline must deal head on with the emotional distress of the moment.


Interpersonal Deficits
Despite their strong desire for deep, meaningful relationships, individuals with borderline personality disorder often have great difficulty in their relationships with others. They may often be excessively demanding of the attention and resources of others. Conversely, they may also become overly forgiving of still others who have caused them harm in the past.

The consequences of these interpersonal skill deficits are often quite devastating. The ability to form healthy, satisfying relationships with others is the most important psychological skill that one can possess. Our relationships make us or break us. Since individuals with borderline have few relationships that pull them towards joy, they sink lower and lower into their own misery, rachmana litzlan. Effective psychotherapy for borderline personality disorder therefore must focus on strengthening the patient’s ability to form positive relationships.

Considering the impact of these different deficits, despair would seem the most rational response to borderline personality disorder. The truth of the matter however is that such despair is unwarranted. While each of these deficits would seem to deliver a lasting blow to personal success, the human spirit is so much stronger than all of the eminent psychologists could ever predict. With love, patience, effective treatment, and siyata d’shmaya, even the most intractable cases can find hope, peace, and power.