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- Does This Patient Need Psychiatric Referral?
- Giftedness and Psychological Abuse in Borderline Personality Disorder
- NonBlind Placebo Trial
- Personal Intelligence
- Psychiatry at JHU
Links and Blum (1990) recently speculated that intrusive overinvolvement associated with criticism, abuse, and a highly malevolent parental attitude may be particularly characteristic of the borderline's childhood caretaker environment. With regard to this scenario, 78% (18/23) of the borderline patients and 29% (11/38) of the controls experienced chronic intrusion/invasion along with constant devaluation and/or chronic attack on autonomy, (x2 = 13.65, df= 1, p < .001). In line with this. Reiser (1986) distinguishes intuitively gifted, depressed, but not borderline individuals who apparently experienced intrusive overinvolvement without conspicuous threat or hostility from caretakers (Miller, 1981), from borderline individuals who were subjected to severe hostility.
There are a number of weaknesses in this study that are often present in long-term clinical research, including small sample size, limited testing instruments, and lack of blind evaluation (Frances, 1990). Data are derived retrospectively from subjective reports and are potentially biased by both observers and patients. On the other hand, some of the results are very strong statistically. Also, self-reports of childhood trauma and abuse have been quite similar throughout a number of studies (Briere & Zaidi, 1989; Herman & Schatzow, 1987; Jacobson, 1989).
DISCUSSION
For clinicians who treat borderline patients, the most striking personality feature is the "flavor" of their involvement in the treatment relationship, particularly their ability both to access and then to strongly influence our private emotions, engendering the classical "countertransference problems/ 'special' treatment relationships" that Zanarini et al. (1990) found to be one of seven "more specific or even pathognomonic features" (p. 166) of BPD. We have presented evidence compatible with the hypothesis that this unusual ability to access private emotions reflects a healthy innate intuitive talent or gift, and that the highly developed skill to influence detected emotional vulnerabilities reflects a learned capability that could develop only though years (Millon, 1987) of constant, often subtle (to an observer), interactions with caretakers who relate to the child in a severely controlling, threatening fashion, and in a biparental situation that isolates the child from significant empathic support or validation (Gunderson & Zanarini, 1989; Kohut, 1971; Links & Blum, 1990).
We propose that this explanation for the interpersonal characteristics of BPD can also provide an understanding of other clinical manifestations of the syndrome. The interactive combination of giftedness and psychological abuse in the genesis of borderline symptomatology is elucidated by attachment theory, which proposes that when there are incompetent, abusive caretakers, the child blames himself or herself and absolves the caretaker in order to maintain a "secure base" (Bowlby, 1988; Crittenden & Ainsworth, 1989; van der Kolk, 1987), that is, in order to maintain the perception that the caretaker is at least "good enough" (Winnicott, 1960) for basic psychological survival. This scenario would be especially significant and complex if the child were intuitively brilliant, and the interaction would be particularly destructive if the parent rejected and assaulted the child for its very perceptions, because the child must then experience himself or herself as profoundly bad for having core mental processes that cannot be stifled. After a childhood of such pervasive requirement to experience black as white and vice versa (Gantt, 1944; Shengold, 1989), the only behavioral clue to giftedness in the adult is a defensive pattern suggesting a very complex yet provocative confusion about self and others. This formulation accounts for the paradoxical combination in the borderline patient of cognitive and affective disarray, enormous distress, and helplessness, coexisting with surprisingly persuasive interpersonal powers (Gutheil, 1989). It also accounts for the observation that intuitive borderlines paradoxically can frequently be perceptively dense, since healthy perceptiveness can be overwhelmed by biases and introjections resulting from parental intrusive intents and behaviors.
The concept of a crucial interaction between social perceptivity and the quality of child-rearing receives support from recent primate and pediatric research. Suomi (1991) found that rhesus monkeys selectively bred to be "high reactive" (i.e., very fearful and anxious in new or challenging situations) and who are highly aware of their environment from birth (i.e., possibly gifted) (Suomi, personal communication, 1991) tend to maintain this anxious pattern to reach a relatively marginal adult adjustment. However, when raised by unusually nurturing foster mothers, such monkeys become the most socially skilled and dominant members of their peer groups. Boyce, Chesney, Kaiser, Alkon-Leonard, and Tschann (1991) report findings suggesting that there is a subset of children with a "heightened sensitivity to the social world" (gifted?) whose developmental and emotional outcomes, ranging from unusually successful to unusually poor, are critically dependent upon the character of early child-rearing conditions (Boyce, personal communication, 1991). It appears that an apparent biogenetic vulnerability may actually reflect an advanced social potential that requires special nurturing (i.e., an appropriate parental "fit") for the proper development of this potential (Brazelton & Cramer, 1990; Thomas & Chess, 1984). It can be extremely important to distinguish a talent requiring such special care from a defect. For instance, we do not say the human infant is defective because it requires very attentive and sensitive care for many more years than any other creature. These issues may be relevant not only to BPD but also to other psychiatric disorders, particularly those involving affects.
There are two published controlled studies that support our findings of Intuitive capacities in borderline patients. In the first, Ladisich and Fell (1988) evaluated empathy in 20 borderline, 20 neurotic, and 19 patients with a history of schizophrenia, all in inpatient group therapy. Patients and group therapists evaluated themselves and other group members using personality trait and social attitude tests, with empathy assessed by calculating how accurately a person could rate other persons' ratings of themselves. The borderline patients scored significantly better than both the neurotic and schizophrenic groups and, in fact, were as good as the therapists, who presumably had more knowledge of the patients. The authors suggested that high empathy (i.e., personal intelligence) in borderline patients might reflect a vulnerability for psychosis.
In the second study. Frank and Hoffman (1986) compared two groups of patients, borderline and neurotic, employing the Brief Exposure Profile of Nonverbal Sensitivity. They demonstrated significantly higher nonverbal sensitivity in the borderline group, which they felt provided empirical confirmation of a "borderline" or symptomatic type of empathy in BPD that developed as a way of contending with maternal emotional neglect. They also found (Hoffman & Frank, 1987) correlations consistent with the hypothesis that a constitutional vulnerability contributes to the nonverbal sensitivity. However, the scientific literature supports the concept that the capacity for empathy is a healthy inborn trait (Brothers, 1989; Neubauer & Neubauer, 1990) rather than an inborn weakness or vulnerability, a susceptibility for psychosis, or a manifestation of childhood stress per se (Cicchetti & Carlson, 1989).
Because there has been no prior consideration of giftedness as having major relevance for etiology and clinical manifestations of BPD, there are no published estimates of its prevalence. The Zanarini et al. (1990) report that 63% of 120 borderline patients engendered countertransference problems and special treatment relationships, and our finding of 74% gifted individuals, suggest the possibility that as many as two thirds to three fourths of borderline individuals have unusually high levels of personal intelligence. In line with this. Bond (1990) reported a pilot study in which two thirds of a small borderline group scored significantly higher for defense mechanisms that included projective identification than a control group of other personality disorders.
Our findings about patterns of parenting behaviors are in line with a preliminary report from Zanarini and Gunderson (1987), who found evidence for chronic verbal abuse by female caretakers, along with inconsistency and physical neglect by male caretakers. Similarly, Soloff and Millward (1983), in a controlled study of 45 BPD inpatients, found a significant pattern of intrusive, controlling, overinvolved mothers, along with underinvolved or absent fathers and a conflictual marital relationship.