Schizophrenia and the Borderline Personality Disorder

Jack Rosberg, Ph.D.
E mail JARosberg@aol.com

This presentation is on the syndrome called schizophrenia and the borderline personality disorder.  Both areas are considered to be very difficult areas for treatment, and also difficult to understand.  However, if you take into consideration that both of these conditions have been treated primarily by physical methods of treatment ever since they have been classified, then I think that we can understand why the results have been so very poor.  To understand these conditions you need to know about the process rather than the end state.  In order to understand these conditions you need to have some understanding of some of the professionals and the environment and the culture that surrounds them, and the treatment centers wherein they receive treatment. 

The attitude we see in the professional world that prevails is the attitude that is stimulated and postulated by the biological theorists and others who do not hold out any hope for these people and tend to influence the professional world to the extent their hopeless and negative feelings becomes a self fulfilling prophecy.  To understand the schizophrenic syndrome and the BPD, we need to understand something beyond the overt symptoms.  We need to have some conception of the logic that develops as a function of the terror that these human beings feel. 

Perhaps as I discuss the problems related to these conditions and their defense mechanisms and the resistances to change, there might be some way of understanding that the greatest defense that these people have are the resistances of the professional world in reference to treating them.

Historically, the term or phrase borderline has been invoked when clinicians noted that a two neat category universe, neurosis and psychosis, contained some confusing cases that were not precisely one thing or not precisely the other.  The term borderline, therefore, is used to bridge a non-contiguous area of meaning into a continuum.  So actually, category is converted into dimension.  This by the way, does not support one etiological theory or another.  Now as far as the dimension is concerned or a continuum, it seems to me that this is designed either to further achieve a better understanding of people and their psychopathology, or an attempt to reduce the unknown in an attempt to reduce and modify anxiety.  But I don’t think it makes any difference, actually.  What the factors are that help people get better are not necessarily the categories that we find to place them in.  What makes the difference in treatment, I think, is the attitude and an understanding of the logic that these people develop in the course of their illness that becomes the tools that effect behavioral changes in these dreadful conditions. 

Often the borderline condition is perceived as a vast wasteland between the neurotic and the psychotic.  This vast wasteland which lies between the neurotic and the psychotic is a condition that is neither schizophrenic nor neurotic. 

A condition that is neither schizophrenic nor manic may be seen as borderline.  And that level that is not in keeping with the functioning neurotic nor with the incapacities of a psychotic can be considered borderline.  However, when we look at that concept we have to understand also that not all neurotics function nor are all psychotics incapacitated. 

The psychoanalysts began to see the borderline as one who did not fit the criteria for analysis and/or was not reachable by analytic techniques.  There were some references made about the borderline condition in the 19th century.  However, the contemporary usage rises from psychoanalytic papers of the 1930’s, amongst which is the work of Wilhelm Reich’s character analysis, which I think gives a broader dimension not only to the understanding of the psychosis but also the neurosis as well, and to the tenacity to which people hold onto these maladaptive conditions. 

Before the term borderline became widely used, one could see the germ of such a notion in Eugen Bleulers correction of Kraeplin’s pessimism about dementia praecox and Freud’s de-emphasis of an organic etiology for what he preferred to call the narcissistic neurosis.  Eugen Bleuler made it clear that not all cases labeled dementia praecox deteriorated as Kraeplin initially believed and thus he introduced more optimism. 

Unfortunately today in reference to schizophrenia, we are much more influenced by the pessimism of Kraeplin than the optimism of Bleuler.  It is my opinion, as a function of my own work, that schizophrenia begins as a terror syndrome and those with schizophrenia regress when in that state of terror to the point and only to that point where the patient feels the safest and then begins to organize around that area of safety a system of defenses to keep him or her safe from intrusions that they perceive as a threat to their lives. 

Freud did not dismiss the organic factors when he began dealing with the population of so called neurotics that he called narcissistic, but he focused his attention more on theories than dynamics.  These theories were not a priori but resulted from his clinical experiences, not like a lot of people who are what I consider to be arm chair theorists and philosophers, such as the biologic theorists who postulate their theories a priori, not as a function of any personal or dynamic involvement with these human beings that we diagnose as schizophrenic and borderline. 

One of the earliest contributors in respect to the psychotherapy of schizophrenia in this country was a very optimistic man, his name was Adolph Meyers.  He and Harry Stack Sullivan in 1922 effected the traditional gloom in the field, and more vigorous efforts therapeutic efforts were expressed by a growing number of psychotherapists with patients who showed more severe psychopathology.  Both Sullivan and Meyers were the first therapists in the country who introduced psychotherapy with schizophrenia as a treatment of choice, rather than relying primarily on the physical methods of treatment.  Just to briefly run down what the physical methods of treatment have been: in the 30’s I can refer to the incredible use of metrazol, wet packs, insulin coma therapy, which were used almost universally with the schizophrenic.  In the 1930’s a Portuguese psychiatrist by the name of Monus invented the prefrontal lobotomy and in the 30’s, 40’s and the 50’s some 50,000 Americans diagnosed as being schizophrenic received the prefrontal lobotomy and he received the Nobel Prize!  In 1938, electro shock therapy was introduced.  After that in the 50’s the neuroleptic drugs were introduced and they were heralded as miracles, it was said at that time, that the mental hospitals would be cleared of schizophrenics by the 1970’s, but we know that has not happened, and we understand that even though it does offer some help, to those very sick people, we need to be aware of its limitations.

The first to give the term borderline formal status was a psychiatrist by the name of Stern, who in 1938 outlined the characteristics of a group of office patients as, to quote him ‘too ill for classical analysis.’  That is another person who could not see the patients as being neurotic and/or psychotic, but had to make a different category because these patients were not candidates for classical analysis.  Some of the characteristics he stated were narcissism, hypersensitivity, and negative therapeutic reactions, which means that the patients reacted to interpretations as if they were unloved or not important enough or not worthwhile considering.  I can see in his findings that the patient’s viewed the analytic interpretations as a method of prying him/her loose from the therapist and of the secondary gains in this symbiotic attachment with the therapist.  There are some who hold there is such a condition as borderline schizophrenia.  Seymour Keaty and his colleagues referred to this category as those patients who exhibit symptoms and characteristics of lesser intensity.  In my opinion, this is not a borderline condition.  This is another expression of schizophrenia because schizophrenia is not only expressed in gross terms, but there are many subtle expressions of the schizophrenic syndrome. 

When the DSM 111 Codes were in effect schizophrenia is diagnosable if that person has had that condition for 6 months or longer.  Acute schizophrenia was replaced by a condition called schizophreniform which obviously is not considered to be a true schizophrenic.  By definition a schizophreniform is that person who has that condition which resembles schizophrenia two weeks, but less than six months, and it is considered a stress related condition which is temporary and is reduced when the stress is reduced. 

BPD cases defy traditional categories.  We are often at a loss as to how to diagnose them within the framework of our standard nomenclature.  There are conflicting viewpoints amongst many of the prominent viewers about the borderline condition.  I find it very interesting that many of the questions that are raised are raised as a function of whether the differences of a patient seen by one reviewer or another are socioeconomic in terms of their background, or what part of the country the reviewer practices in, and what their respective theoretical groundings are.  The differences that are raised are important to understand when we think in terms of how therapists and theorists look at the human process.  We cannot separate ourselves from our perceptions, our background, and our history.  And, that’s not so bad, but we have to understand that we all have opinions that contaminate our objectivity. 

What Kernberg diagnoses as borderline is considered a character neurosis by Giavoncini.  Something in that:  If the character neurosis resembles the character disorder, which I am inclined to believe that it really does, we may have something that is in common, in my estimation, in all emotional disorders.  I see the character disorder as an acquired defensive system to protect the basic condition which has become a lifestyle or survival mechanism for the schizophrenic and also the borderline. 

Masterson places the fixation point for borderline patients at the separation indivuation point, which I consider to be of paramount importance.  According to Margaret Mahlers ideas about symbiosis in the normal, symbiosis leads to separation and indivuation in the early part of the infant’s life.  However, in the borderline condition the fear of loss of detachment create an intolerable anxiety which inhibits or prevents indivuation.  Compare this to the schizophrenic.  They may see attachments as life menacing and they all have a terror of annihilation.

Some of the characteristics of the borderline condition as follows are compared with the schizophrenic reaction.  There is an awareness of social convention with the borderline even if they are in defiance of them.  They may lead socially active lives outside of their families and feel they get along, even if they don’t get along.  They do not work effectively.  Neurotic depressives, for an example, are more significantly stable in the work history and are more likely to have areas of special achievement. 

Schizophrenics are less likely to have an active social life involving groups of people and are more unsuccessful socioeconomically than the borderline personality.  The borderline personality looks socially more like the neurotic but they behave vocationally more like the schizophrenic.  Borderline patients act out in a variety of ways: Self destructive acts, destructive acts towards others, anti social behavior, such as drug and alcohol abuse.  They frequently overdose, threaten suicide, mutilate themselves, and make manipulative suicidal attempts.  According to the literature, this seems to be more with the borderline personality than with the schizophrenic or the neurotic population.  Affect in the borderline personality runs the gamut; depression, anxiety, terror.  These patients report frequently that life isn’t worth living.  Many relate depression to chronic feelings of loneliness or emptiness.  Anger is expressed by irritability or sarcasm or in hysterical, delusional like accusations.

Benedetti, the Swiss psychiatrist, whose borderline concept is widely respected lists main three main clinical characteristics, hypocondriasis, ideas of reference and depersonalization.  I see this as an interesting formulation which suggests to me that a puff of wind would or might push this patient into a severe psychotic like episode.  You know that many schizophrenics express hypochondriacal symptoms.  Ideas of reference could easily become delusions of reference.  I think that the difference is in degree rather than in kind, and of course, depersonalization is a characteristic of schizophrenic.

I need to point out again that the major differences may be the detachment fear and its major anxiety of fear of object loss, and with the schizophrenic, the terror of annihilation.
Kernberg’s model of the borderline and what I think are the critical points are reality testing and ego integration. 

Reality testing demarcates the psychotic structure from the borderline and ego integration is more faulty with the borderline than with the neurotic.  It has to do with the area of interpersonal relations.  Reality testing comes and goes with the borderline.  Very often with the psychotic structure reality testing has a different hue and color to it.  There are sharp contradictions in attitude that interfere with everyday life with the borderline personality.  What’s here this hour is in conflict with the next.  What is committed at this moment is in juxtaposition with the next moment.  It seems confusing however it is understandable if you understand the logic of the borderline personality in view of the tremendous anxiety once again related to individuation which is perceived by the borderline personality as the loss of object relations.  That is something that I would like to speculate about.  To me the loss of object relations by the borderline personality is tantamount to the identity crisis and the loss of identity suffered by the schizophrenic during the onset of the acute reaction and the terror syndrome.  There are other important indicators to the borderline, perhaps more non-specific which also are true by the way, in many cases with the schizophrenic syndrome.  Let me recite some of them.  The borderline has low anxiety tolerance and has a higher vulnerability to stress than the neurotic.  Also true of the schizophrenic.  The borderline, it’s said, has a poor record in school, work; so with the schizophrenic.  There are other important features: hypochondriacal behavior can often be confused with psychotic delusions.  However, when one carefully evaluates what is going on with the borderline, one finds that these feelings, these hypochondriacal fears are not as persistent with the borderline as it is with the schizophrenic who has delusions, physical hallucinations in reference to all kinds of terminal illness.  Hysteria, which induces paranoid ideation, and again creates a language like the schizophrenic is only temporary.  What I mean by a language like the schizophrenic is that hysteria will bring all kinds of accusations and paranoid like thoughts about people around the person who suffers the condition and the therapist as well.  Poor impulse control in therapy is expressed by projection.  Poor impulse control is another feature of the borderline condition, and also the schizophrenic.  In therapy, this is expressed by projection which puts the blame on the therapist for all the wrong doings and harmful things during the course of the patient’s life in the past and at the present time.  Now, this should not be confused with the delusional transference with the schizophrenic which puts the current therapist in the position of responsibility for the feelings of the patient that his/her life is threatened, or he/she faces annihilation or he/she is responsible for everything that ever happened during the course of that patient’s life which is negative.  In treatment with the borderline personality some therapists express concern that direct confrontation approach is a counter productive technique.  They say this, because they fear that any exacerbating influences may break down the defenses and cause a psychotic regression.  This is not true when you have a therapeutic alliance.  There are many possible therapies given the condition of the patient and changes in approaches regarding therapy as the patient changes. 

There are many treatment approaches and possibilities with the borderline personality and with the schizophrenic.  The active use of confrontation or the interpretation of the here and now rather than the classical type of interpretation or the interpretation of content.  And I think it is terribly important to understand whether or not when we hear content from the patient whether the content is designed to confuse us rather than to help us understand the underlying factors.  It is quite clear that because of their fear of change and/or loss that they do everything they can to perpetuate their condition.  Another treatment approach is an intrusive approach that is, putting pressure on the patient’s inner resources, activating the potential for reality testing which makes the patient more accessible to psychotherapy.  Certainly the same is true for the schizophrenic syndrome.  However, with the schizophrenic we make efforts to overcome their resistances in order to help them understand that what they see is really not in fact the case.  Medication in moderation may be useful if it is used with psychotherapy.  Without psychotherapy, it simply doesn’t do any more than mask the symptoms.  I have found with patients who begin to respond to psychotherapy that medication becomes more effective.  It is said that medication makes the patients more accessible to psychotherapy, but I am inclined to think that effective psychotherapy makes medication more useable.  A hospital can be useful, or can be very dangerous, if not used for short periods with the borderline, because hospitalization becomes an omnipotent shrine or refuge for the patient and therefore, hospitals become iatrogenic, in fact, they make the patient worse.  It is not the best possible place for treatment, however, in view of what we have as far as other treatment centers are concerned, there seems to be very little alternative for any patient who is experiencing an acute reaction.  Other psychotherapeutic ways, crisis intervention, important, important, in terms of the involvement of the therapist with the patient as much as can be done rather than relying primarily on the physical methods of treatment such as medication or restraints.  I think that we do not understand well enough that change comes as a function of pain and suffering which none of us likes to deal with as clinicians.  Sometimes, we make an urgent effort to overcome that pain without involving ourselves as intimately as we should and in that sense, I think, we don’t give people a choice and an understanding that they are not alone in the world and rob them of their dignity. 

Other psychotherapeutic ways include supportive therapy which at times is a useful technique however, unfortunately like so many other things that are considered to be therapeutic, it is over utilized by therapists because they can’t be consistent in terms of dealing with the patient in an intimate way.  They don’t involve themselves with any degree of effort in a consistent way.  Reality therapy is effective at times.  Long term  therapy aimed at character defenses is a very important effort that needs to be made by the therapist in order to overcome the character defenses if that individual is to individuate and to lead an independent adult life.  The character disorder is a defensive structure that supports this condition and it also supports the condition of schizophrenia as well.  I consider the character disorder to be the backbone of schizophrenia and it certainly perpetuates the condition called borderline personality disorder. 

Now the needs and the demands of the borderline and the schizophrenic place an enormous burden on the therapist which can give rise to counter-transference reactions that make the therapist act so inappropriately and so counterproductively and so destructively.  And, one sees very often where the therapist may enter into a therapeutic conspiracy with the personality who has this diagnosis in order to avoid the contact that they need to make in order to make corrective behavioral changes.  There are many things that ensue as a function of that.  One is the worsening of the patient’s condition,  one is the perpetuation of the condition of the patient, one is getting rid of the patient because you can’t stand the pressures that are on you as therapists. 

The therapist’s involvement in the borderline personality treatment and also with a schizophrenic must be very strong and strength is expressed in a number of different ways.  The therapist must feel free enough under certain conditions to impose limits and structure.  The therapist must have enough strength to control impulses and acting out. When the therapist helps the patient regain controls over his impulses and his acting out behavior, there can be a gradual reduction of the imposed limits. 

In my opinion, regarding schizophrenia and the borderline condition there are differences which should direct the therapist to respond with greater sensitivity.  These are very, very sick human beings who require dedicated and involved therapists, and therapists who are spontaneous, intuitive and also not too loose or too careful.  Also, not too terrified of rocking the boat and effecting the homeostatic condition of the patient.  Changes about as a function of the artful therapist who, when the therapeutic alliance is achieved, is willing to exercise tactics needed to overcome the defensive characteristics of the borderline condition and the schizophrenic syndrome and reinforce the healthy areas that all human being have somewhere in their lives no matter how sick they are.