The Paradox of Borderline Personality Disorder

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Borderline personality disorder (BPD) is classified as a severe and persistent mental disorder that causes considerable morbidity and mortality. Roughly 10 percent of people with BPD will die by suicide (Paris, 2019). The economic costs associated with BPD are roughly double those associated with major depression (Soeteman, Hakkaart-van Roijen, Verheul, & Busschbach, 2008).

The birth of the concept of borderline personality stems from the 1950s and 60s when authors such as Knight (1953), Main (1957), Frosch (1964), and Grinker and colleagues (Grinker, Werble, & Drye, 1968) began documenting patients whose problems appeared to exist between the border of the neuroses and the psychoses. Because they rarely reported hallucinations or delusions, these patients could not be considered psychotic, but they also lacked the consistency of neurotic patients; as McWilliams (2011) puts it, the only stable thing about them was their marked instability. Borrowing from the work of Cleckley (1941), Bradley and Westen (2005) describe borderline patients as having only a “mask of sanity.”

It was John Gunderson and colleagues (e.g., Gunderson & Singer, 1975) at Harvard who operationalized the diagnosis of borderline personality disorder, and the disorder was listed for the first time in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. Kernberg's contributions to the broader concept of borderline personality organization (e.g., Kernberg, 1984) have been instrumental in understanding the psychodynamics of these patients.

While much has been written about borderline patients and their treatment, relatively little attention is given in the modern literature to one of the hallmark features of the disorder: the patient’s characteristic engagement in self-contradictory, paradoxical, and self-defeating behavior. I have said previously that the great paradox of BPD is that while the patient's greatest fear is abandonment, they will act in ways that virtually ensure they will be abandoned (Ruffalo, 2023).

Thus, I submit that BPD is fundamentally a disorder of self-contradiction. Understanding these dynamics will likely yield benefits in conceptualization and treatment.

Cyclical Psychodynamics

A number of psychodynamic theories of the nature, pathogenesis, and treatment of BPD have been advanced since the 1970s. Object relations perspectives, for instance, emphasize how borderline patients internalize relationship patterns from their interactions with their primary caregivers (e.g., Masterson, 1972). Kernberg's focus on transference issues has revolutionized treatment. (I offer a brief review of a general psychodynamic theory of BPD here and here.)

In 1977, psychologist Paul Wachtel described a process he called "cyclical psychodynamics," by which borderline patients often inadvertently elicit precisely what they most fear. The brief vignette below depicts this phenomenon.

Anna has been dating her boyfriend for eight months. After a period of intense infatuation, she becomes increasingly suspicious of his intentions.

If he doesn't text her back within a short period of time, she accuses him of cheating on her. She begins to attribute malevolence to benign interactions. Every few days, a fight occurs. Often, when her boyfriend expresses love for her and a desire to further their relationship, she responds by pushing him away.

The relationship is marked by a chaotic pattern. When some semblance of stability is reached, Anna inevitably "stirs something up" by criticizing her boyfriend or pointing out his flaws. Sometimes she withdraws completely.

Ultimately, her boyfriend cannot stand the chaos any longer and breaks up with her. Despite his love for her, he cannot fathom a life of such instability. Anna is left heartbroken, wondering why her boyfriend would do such a thing to her.

The vignette above depicts the self-contradiction inherent in borderline pathology. So fearful of losing her boyfriend, Anna behaves in ways that serve only to drive him away. Although she expresses a desire for true love, her conduct in essence makes this an impossibility, for no healthy person is likely to endure the ongoing assaults on their character and psyche at the hands of someone who, at times, sees them only as a bad actor.

Furthermore, it depicts a psychodynamic process known as identification with the aggressor. While Anna's behavior contributed to the downfall of her relationship with her boyfriend, she ultimately ends up blaming him for leaving. This reversal of victim-victimizer roles, first identified by the psychoanalyst Sándor Ferenczi, is a common defense in borderline disorders.

Making Sense of Self-Contradiction

Why do patients with BPD behave in such paradoxical ways? We must remember that borderline patients are driven by not one, but two, intense anxieties. While it is rejection or abandonment anxiety ("fear of abandonment") that receives the most clinical attention—since it is usually what the patient most frequently complains of—a second anxiety, enmeshment anxiety, fuels much of the chaotic push-pull patterning that characterizes the borderline's interpersonal life.

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The borderline patient is, in essence, caught in a dilemma. When they feel close to another person, their fears of intimacy kick in; when there is too much distance, they feel traumatically abandoned and rejected. This central conflict between intimacy and rejection results in their going back and forth in relationships, in which neither closeness nor distance is comfortable (McWilliams, 2011). Because love for these patients is intricately tied to pain, no stable middle ground exists.

As a result, the patient's loved ones—and especially their romantic partners—are placed into an untenable situation; either they attempt to reassure the patient of their love and commitment and are met with coldness, distance, or hostility, or they take a step back and are told that they are being insensitive and rejecting. That is to say that the patient has placed the partner into a double bind, a lose-lose situation. As Bateson and colleagues (Bateson, Jackson, Haley, & Weakland, 1956) described, the consequences of double bind scenarios for the recipient of such communications include frustration, confusion, and a sense that one is "losing one’s mind."

Ultimately and inevitably, via the process of cyclical psychodynamics, the person with BPD brings about the outcome they so desperately seek to avoid; despite their proclamations of needing and desiring closeness in a relationship, they destroy any such chance. The partner leaves, and if the psychological conflicts remain unresolved, the cycle repeats in aeternum.

Conclusion

A hallmark feature of the borderline syndrome is a pattern of self-defeating, paradoxical behavior attributable to the patient's enduring conflict between intimacy and abandonment. It is as if these people continually shoot themselves in the foot without realizing that they, themselves, are holding the gun. It is therefore suggested that BPD be considered fundamentally a disorder of self-contradiction.

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