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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
It appears that different patterns of caretaker abuse tend to be etiological for differing clinical syndromes, with terrorizing and dramatic abuse, particularly sexual and physical, predominant in the history of multiple personality disorder (Putnam, 1989), and severe psychological abuse that pervasively and insidiously affects routine workings of the mind predominant in the history of BPD. The finding of 100% psychological abuse suggests that this is a necessary etiological factor for BPD, and that giftedness is frequently present but not essential. Although an emotionally gifted child would be uniquely vulnerable to, and characteristically responsive to, such caretaker behaviors and attitudes, severely abusive and chaotic family environments could be expected to elicit significant borderline characteristics in almost anyone, with and without clinical manifestations of intuitive talents. The literature also suggests that borderline characteristics can be engendered by reasonably well-meaning, even generally empathic, parents who have very strongly held but very faulty and severe child-raising concepts, or who respond very negatively or Inappropriately to certain highly stressful phenomena such as difficult temperaments, significantly defective impulse, attention or affect regulation, severe learning disabilities, and marked hyperactivity (Feldman & Guttman, 1984; Gunderson & Zanarini, 1989; Kernberg, 1975; Linehan, 1989; Miller, 1983). In all these scenarios, the essential factor in the development of borderline symptomatology is severely defective caretaker empathy for, and response to, the child's psychological state, that is, broadly speaking, psychological abuse. Biogenetic factors such as a child's physical appearance and behaviors would not be a major antecedent for BPD per se, as the development of such psychopathology would not be expected with appropriate parenting (Brazelton & Cramer, 1990; Miller, 1981; Werner, 1989).
NARCISSISTIC CHARACTERISTICS IN PARENTS
Of special interest to us was the high occurrence of a dominating, un-empathic parent who exhibited impressive narcissistic characteristics and who appeared to have low or defective (Gardner, 1983; Gould, 1991; Mountcastle, 1975) innate personal intelligence, an exceptionally poor fit (Thomas & Chess, 1984) for an emotionally gifted child. The very nature of pathological narcissism (Kernberg, 1975; Kohut, 1971) includes primitive defenses that would be very disturbing such as splitting with alternating mental states, exploitativeness and intimidating rage in response to envied qualities and autonomous strivings of significant others. Possibly contributing to the relative scarcity of speculation about parental narcissism in the genesis of BPD is the skewing of criteria for NPD toward identifying relatively overt exploitative behaviors seen in stereotypical male roles rather than in subtle, disguised, or concealed behaviors (Gunderson, Ronningstam, & Bodkin, 1990) common in parenting.
The domain of NPD as it relates to BPD requires a great deal of study, considering that there may be very different forms and expressions of narcissism, such as states versus traits, and including individuals with varying potentials to experience empathy and caring. Widiger and Frances (1988) point out that psychodiagnostic research has not demonstrated a substantial overlap of these two disorders. We are investigating the possibility that individuals who develop these conditions tend to be at extremes of personal intelligence, with psychopathology often reflecting complex interactions of caretakers at one extreme with offspring at the other.
THERAPEUTIC APPROACHES
Validation of the etiology we have proposed may lead to new therapeutic strategies for BPD that will have significant consequence both for rate of improvement and for decrease in the high suicide rate early in treatment when hope is most often abandoned (Frances, 1990). We believe that the current average of 15 or more years before recovery (Gunderson & Zanarini, 1989) may well reflect, in part, negative or devaluative formulations about these individuals, their histories, and prognosis.
We are currently investigating the effect of validating, when appropriate, six major characteristics of borderline patients that are either positive or encouragingly explanatory: exceptional personal intelligence; history of severe psychological abuse/neglect with concomitant enormous suffering; compulsive self-blame and self-devaluation as attachment characteristics; "staying power"; "real self versus introjected narcissistic characteristics of abusers; and the absolute right to experience their innate capacity for freely enjoying their feelings, their perceptions, and thoughts. We are also informing patients of recent hard data that the natural, long-term course for most borderline individuals is improvement to essentially normal functioning, which means we are able to communicate optimism that is sincere, is confidently based on knowledge, and carries no false bravado that an intuitive patient might detect (Frances. 1990; Perry, Herman, van der Kolk. & Hoke. 1990; Stone, 1990a).
By validating personal intelligence or giftedness as an innate characteristic, we can provide a therapeutic "mirroring" or "holding environment" (Kohut. 1971; Lear. 1990; Warnes, 1981) in which the borderline individual experiences an unconditionally and inherently good quality. Krohn (1974) grasped the importance of recognizing and validating occasional penetrating perceptions by borderline patients, but he did not remark on the possibility of an underlying talent. Similarly, Frank and Hoffman (1986) recommended giving more credence to perceptions of borderline patients and helping them learn to modulate an abnormal sensitivity to nonverbal cues. Carter and Rinsley (1977) commented on the value of recognizing that the borderline patient's intuitive perceptions can be accurate but did not consider the therapeutic benefit of verbalizing this to the patient.
Validation of chronic physical, sexual, and psychological caretaker abuse is essential for the gradual dissolution of profound shame, self-blame, self-hate, and self-loathing (Miller, 1983; Perry et al., 1990). We find that it is absolutely necessary for Intuitive patients to understand relevant moment-to-moment behaviors, intents, and even dynamics of their parents and others. "Staying power" refers to the relentless urgency and effort to survive destructive childhoods and endless suffering, and to be complete persons.
CONCLUSIONS
The etiology of BPD remains one of the significant challenges for psychiatry, moreso now that it has been established as a clearly defined syndrome not specifically related to schizophrenia or to depression. We have presented evidence that an understanding of BPD may be found by investigating the Interaction of a child's healthy intuitive talents and developmental requirements with severe psychological abuse from caretakers. The concept of giftedness in borderline individuals may have important implications for an Improved psychotherapeutic environment, which in turn may significantly alter the prognosis, suicide rate, and length of treatment for patients who are generally viewed in a rather negative conceptual framework.