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In the second study, Frank and Hoffman (1986) compared two groups of patients, 10 borderline and 14 neurotic, using the Profile of Nonverbal Sensitivity (brief exposure PONS; Rosenthal, Hall, DiMatteo, Rogers, & Archer, 1979). They demonstrated significantly higher nonverbal sensitivity in the borderline group, which they felt provided empirical evidence for the concept of borderline empathy, the apparent ability of borderlines to accurately tune in to the internal state of others. They therefore suggested an empathic ability in BPD, but they also proposed that the empathy is a "borderline" or pathology-based type that developed as a way of contending with maternal emotional neglect. In a subsequent paper, Hoffman and Frank (1987) presented some correlations from the same study that were consistent with the additional possibility of a constitutional vulnerability contributing to the nonverbal sensitivity. However, the literature indicates that the capacity for empathy and perceptiveness involves an inborn talent (Brothers, 1989; Davis et al., 1994; Neubauer & Neubauer, 1990; Rushton, Fulker, Neale, Nias, & Eysenck, 1986), rather than being an inborn weakness, a vulnerability to psychosis, or a manifestation of childhood stress per se.
The findings and observations discussed have only recently led to studies designed to evaluate their possible etiologic significance. A review of the history of BPD research reveals why such studies were so late in coming (Park, 1994). The condition was not identified until fairly recently and was originally thought to be a variant of or "borderline" to schizophrenia, hence the name. Seminal research by Gunderson in the 1970s identified objective diagnostic criteria that engendered many studies involving large populations of borderline patients (Gunderson, 1982). These studies revealed that BPD was not a variant of psychotic illness, leading to labeling of the condition as a personality disorder of unknown etiology. Once it became clear that the etiology of BPD could not be understood from findings about schizophrenia, numerous etiologic theories were advanced including proposals that BPD is a variant of depressive illness, that there are various neurobiological vulnerabilities, and that BPD is engendered by factors in childhood such as parental separations and loss, family conflict, and parental psychopathological behaviors toward offspring including neglect, overinvolvement, and overprotection (Gunderson & Zanarini, 1989; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989). A complicating issue has been clinicians' reactions to the personal discomfort these patients evoke. With their perceptive talent imbedded in the service of self-protection, neediness, control, and rage, borderline patients have been negatively viewed by many clinicians as deliberate manipulators who are unreliable, will not respond to treatment, are unpredictably suicidal, and who are troublemakers to be avoided if possible. "Borderline" became a pejorative word that labeled disliked patients, leading to misdiagnoses that further delayed an understanding of the syndrome (Frances, First, & Pincus, 1995).
Although there were clinical reports of serious abuse during the childhoods of borderline patients, the first controlled studies of abuse histories did not reach print until the late 1980s (Herman, Perry, & van der Kolk, 1989; Links, Steiner, Offord, & Eppel, 1988; Zanarini et al., 1989). These and many subsequent studies revealed an enormous amount of physical and sexual abuse reported by a majority of borderline patients. The patients did not seem to recognize their experiences as abusive or to report them spontaneously (Shengold, 1989). Zanarini et al. (1989) investigated the occurrence of caregiver verbal or psychological abuse, defined as chronically devaluative or blaming statements and found that it was by far the most common form of abuse (other than neglect, which they did not categorize as abuse), occurring in 72% of 50 borderline patients. Psychological abuse was the only form of abuse distinguishing the BPD group from each of the control groups with a probability of error of less than 5%. Similarly, Stone (1990a) found that 73% of 15 BPD patients reported a history of intense verbal abuse with physical and sexual abuse occurring at a lesser frequency. In spite of its prevalence among borderline patients, researchers did not focus on the verbal abuse, targeting instead the less frequent histories of physical and sexual abuse. However, we proposed that the critical etiological finding was the psychological abuse, and we expected an even higher frequency would be found if more categories of psychological abuse were examined (Park et al., 1992). Further, the enduring damage from physical and sexual abuse to the body stems from the accompanying abuse of the mind (Garbarino, Guttman, & Seeley, 1986; Hart & Brassard, 1987). Subsequent to completion of our study, Gallagher, Flye, Hurt, Stone, and Hull (1992) reported on the recollected histories of various degrees of verbal abuse in a sample of 22 borderline women, with 86% acknowledging significant degrees of such abuse.
Mental health experts and participants in the child abuse and neglect movement have focused increasingly on psychological or emotional abuse and neglect, as it may be the most insidious, prevalent, and destructive form of childhood abuse (Garbarino et al., 1986; Hart & Brassard, 1987; McGee & Wolfe, 1991). For instance, one can imagine a physically abused child still experiencing inner psychological freedom to have his or her own thoughts and feelings, but psychological freedom could be largely eliminated if the assault is directed to the thoughts and feelings themselves (Stolorow & Brandchaft, 1987). Such head-on confrontation is actually an attack on the core machinery of a child's personal intelligence, because it obstructs and damages the capacity to know and understand oneself and others, including even the capacity to know that one has been abused (Fonagy et al., 1995; Hart & Brassard, 1987; Shengold, 1989). Interference with, as well as neglect of, this developmental requirement may be a necessary condition for most adolescent and adult psychopathology (Park, 1992). Developmental literature and longitudinal studies, as well as primate research, provide convincing evidence that it is not the characteristics of children, such as defects and vulnerabilities, that should be considered as the predominant factors actively engendering adult psychopathology, but rather a defective caregiver or cultural environment that is misaligned with the child's psychological characteristics and requirements (Bowlby, 1988; Byne & Parsons, 1993; Greenspan, 1992; Lidz, 1990; Tienari et al., 1991; Rorty, Yager, & Rossotto, 1994; Vaillant, 1977; Wemer, 1989).
We summarized salient features of BPD and searched for a pattern. Those features are:
- The extreme suffering, self-hate, anger, identity disturbance, emptiness, and fear of abandonment.
- Frequent co-occurrence of chronic depression and posttraumatic stress disorder, as well as dissociative experiences suggesting possible relationship to dissociative identity disorder.
- General history of severe, pervasive psychological abuse as well as frequent history of physical and sexual abuse.
- The chronic, intense, failed search for intimacy, along with great distrust.
- Evidence of perceptive talents, a capacity for empathic response, and the perversion of these characteristics.
It seemed likely, based on the aforementioned characteristics, that chronic and severe assault throughout childhood on self-esteem and on detected autonomous mental processes of the child must be the essential source of the syndrome. This could provide an explanation for items 1-3 but would not fully account for items 4 or 5.
The perceptive talents and the enduring search for intimacy are perplexing. Childhood rejection, abuse, and invalidation frequently result in an impoverished mental life, in diminished perceptivity, empathy, and introspection, in abusive behaviors, and probably in diminished psychological mindedness (Alverez, Schonbar, & Farber, 1993; Bowlby, 1984; Cichetti & Carlson, 1989; Goleman, 1995; Hunt, 1990; Montagu, 1978; Ressler & Shachtman, 1992; Shengold, 1989; van der Kolk, 1987b). We asked ourselves why borderlines characteristically persist in a lifelong search for self-understanding and love, why they retain the capacity for caring about others, why they are so psychologically minded that they return again and again for psychotherapeutic help despite prior failed treatment, why borderline mothers are so often intensely preoccupied with being good mothers, and why most borderline patients recover after years of troubled self-examination. We concluded that there must be an inborn cognitive characteristic at work here, because nothing in their deprived childhood could account for this staying power (Park et al., 1992; Shengold, 1989).
Miller's book (1981) about abused, gifted children also alerted us to the possibility of an inborn characteristic. By "gifted" she referred to: "an amazing ability to perceive and respond intuitively" (p. 8); "lively people who are especially capable of differentiated feelings" (p. 9); "attentive, lively, sensitive" (p. 10); "great intensity of feelings, depth of experience, curiosity, intelligence, quickness, and ability to be critical" (p. 97). She described examples of extreme suffering of people who were apparently gifted and also psychologically abused by caregivers, the same pattern we found in our borderline patients.