Thursday, July 25, 2013

Disturbed Sense of Identity in Borderline Personality Disorder: Part 3

Hey! Hey look! It’s the think that I wanted to talk about all along! Finally! All the exclamation marks!!!! Forgive my underlining ALL THE THINGS. This is the important stuff. Sorry. Read on =)



Carsten Rene´ Jørgensen, PhD


IDENTITY DIFFUSION AND BORDERLINE PATHOLOGY

In Grinker, Werble, & Drye’s (1968, p. 176) classical empirical study of borderline conditions, absence of indication of self-identity is listed as one of the four principal characteristics of the borderline syndrome. Similarly, Spitzer, Endicott, & Gibbon (1979) found that identity disturbance is one of the defining criteria for the borderline disorder. According to the prevailing psychoanalytic conceptualization, identity diffusion is one of the three main characteristics of borderline personality organization (Kernberg, 1984). In addition to this, one could argue that the borderline patient’s proneness for regression in stressful and unstructured situations is intimately related to identity diffusion. People who lack an inner compass and do not have access to a coherent understanding of the self and the outer world will be more vulnerable in unstructured situations, and more inclined to use primitive defense mechanisms. In Kernberg’s model, primitive psychological defenses and identity diffusion are closely linked and both are hypothesized as being intimately linked with regressive loss of control and negative affect  (Lenzenweger, Clarkin, Kernberg, & Foelsch, 2001). Primitive defense mechanisms, in particular splitting, form an essential part of the process that underlies identity diffusion. However, one has to distinguish between, on the one hand, pathological identity diffusion in borderline patients and, on the other hand, less severe and more transient identity diffusion and ‘normal’ identity crisis in adolescence. The identity diffusion, Kernberg and others are speaking of in borderline patients, is quite different from the identity problems, identity conflicts and adaptive identity diffusion of ‘normal’ late adolescents. One of the things these two groups have in common is a lack of—or deficits in—self-definition. The important difference is that the higher functioning adolescent with (momentary) identity problems has a fundamentally secure sense of self and the structural basis for eventually forming an identity (Marcia, 1989). The root of identity diffusion in borderline patients is to be found much earlier in life than during adolescence. They cannot commit themselves to the world, other people and long-term goals because— in a sense—there is no stable self or inner core to make these commitments.


Identity Diffusion: People who lack an inner compass and do not have access to a coherent understanding of the self and the outer world who are more vulnerable in unstructured situations, and are more inclined to use primitive defense mechanisms, are more prone to regression in stressful and unstructured situations, and tend to fuse maladaptively to those around them. Primitive defense mechanisms, in particular splitting, form an essential part of the process that underlies identity diffusion.

It is not uncommon for adolescents and your otherwise “normal” people to experience periods of identity diffusion. The main difference is for these people the underlying periods of diffusion or crisis are temporary but will eventually go back to their previously or otherwise steady-state. This is not so for those of us with BPD. We typically stay in this period of flux or uncertainty, constantly grasping and trying to blend or fuse, struggling to find a place to fit our identity in with the world where it otherwise doesn’t seem to fit.


Moreover, otherwise normal adolescents exposed to an identity crisis do not display the deep-seated, chronic pathology of object-relationships (Akhtar, 1992) frequently found among borderline patients. At the other extreme, identity diffusion must be differentiated from identity fragmentation with bizarre transformations of self-experience and breakdown of the borders of one’s identity often seen in psychotic decompensation. Empirical studies (Marcia, 1980, 1993, 1994) have related—primarily less severe, more adaptive and temporary forms of—identity diffusion to higher levels of anxiety, lower self-esteem, deficits in autonomous functioning, pre-conventional or conventional moral reasoning, problems with intimacy (tendency to withdraw) and disorganized (less systematic and rational) thinking. In DSM-IV and ICD-10, identity diffusion is listed as one of several equally important diagnostic criteria for borderline personality disorder.


The reluctance to emphasize some diagnostic criteria in preference to others is one of the more severe deficits in our authorized diagnostic systems. From a psychoanalytic point of view, severe and more permanent identity diffusion“problems in establishing and maintaining a stable and coherent sense of self” (Gunderson, 1984, p. 8)—is one of the most important diagnostic criteria for borderline personality disorders (BPD) and other disorders rooted in borderline personality organization (BPO) (Kernberg, 1984). Kernberg (2004) even claims, that “the key anchoring point of the differential diagnosis of milder types of character pathology and neurotic personality organization, on the one hand, and severe character pathology and borderline personality on the other, is the presence of normal identity integration as opposed to the syndrome of identity diffusion.” Existing empirical studies (Clarkin, Widiger, Frances, Hurt, & Gilmore, 1983; Widiger, Frances, Warner, & Bluhm, 1986; Pfohl et al., 1986; Modestin, Oberson, & Erni, 1998, Fossati et al., 1999) of the importance of identity diffusion in personality disorders, however, have shown inconsistent results. Most of the studies (except Modestin et al., 1998 and Fossati et al., 1999) have used the diagnostic criteria from DSM-III. Here identity diffusion is narrowly defined in terms of “severe subjective distress regarding the inability to integrate aspects of the self to a relatively coherent and acceptable sense of self” and “uncertainty about a variety of issues relating to identity, including long-term goals, career choice, friendship patterns, sexual orientation and behavior, religious identification, moral value systems and group loyalties.” With the introduction of DSM-IV, the definition was changed to “markedly and persistently unstable self-image or sense of self.” It is therefore unclear to what extent the empirical findings (based on DSM-III) can be generalized to the relatively vague definition of identity diffusion used in DSM-IV. In one of the earliest studies, Clarkin and colleagues (1983) found that identity diffusion in itself is not an especially useful indicator of borderline personality disorder (BPD). However, the combination of identity disturbance and unstable/intense relationships was found to be “a very specific and sensitive indicator” of BPD.


Accordingly, if a person has unstable/intense relationships and marked disturbances in identity, the BPD-diagnosis can be made with certainty. Moreover, Hull, Clarkin, and Kakuma (1993, p. 506) demonstrated that “the severity of the borderline patient’s identity and interpersonal problems was predictive of the course of treatment over 6 months of hospitalization.” Apparently, identity diffusion and unstable relationships represent two important dimensions of the borderline disorder. However, factor analysis from two independent studies (Clarkin, Hull, & Hurt, 1993; Blais, Hilsenroth, & Castlebury, 1997) has indicated that identity diffusion and interpersonal problems, as they are defined in the DSM-system, represent one common factor. Thus, if identity diffusion and interpersonal problems represent two independent factors it has not been possible to differentiate sufficiently between them.


Results from a study by Widiger et al. (1986) suggest that identity disturbance in itself “may be a strong indicator of the borderline disorder” (p. 49). Identity disturbance obtained the highest positive predictive power (.87) of all eight (DSM-III) diagnostic criteria for BPD, which means that identity disturbance was relatively specific for BPD-patients. On the other hand, identity disturbance also obtained the lowest (.50) negative predictive power (the probability of not having a disorder given the absence of the symptom), which means that a relatively large part of the examined patients who did not meet the diagnostic criteria for identity disturbance nevertheless had a borderline personality disorder. In the Clarkin et al. (1993) study identity disturbance obtained a moderate positive predictive power (.59). Pfohl et al. (1986) and Modestin et al. (1987) similarly found a moderate positive predictive power (.63 and .45 respectively) for identity disturbance. Pfohl et al. (1986) found a very high (.94) negative predictive value (the probability that a given patient does not meet the full criteria for BPD, given that identity disturbance is not present) and high sensitivity (.82) for identity disturbance. Some of the most significant results have been presented by Fossati et al., 1999. In a study of the latent structure of the DSM-IV borderline personality disorder criteria they found high sensitivity (.82) and high negative predictive value (.95) for identity disturbance and they conclude that unstable relationships and identity disturbance are the two main characteristics and most relevant diagnostic criteria of the borderline disorder.


I’m not that interested in this aspect. Trying to find these kinds of patterns in the human experience is ludicrous. Even identical twins will experience life differently and have a probability of different outcomes given different environments and different circumstances.


The inconsistency in the presented results is probably due in part to differences in the studied populations. For example, the Clarkin et al. study used a group of out-patients whereas the study by Widiger et al.was based on a group of presumably more severely disturbed in-patients. Moreover, the studied populations were relatively small (n = 84 − 131) and only a minority of the patients had a borderline disorder. In conclusion, identity disturbance does not occur exclusively in borderline patients—a finding that apparently is in keeping with Kernberg’s broader concept of borderline personality organization—and it is not found in all borderline patients—something that might compromise the psychoanalytic idea of identity diffusion as being one of the defining characteristics of the borderline disorder. Nevertheless, identity disturbance is an important part of borderline pathology and in their study of identity disturbance in personality disorders Modest in et al. (1998, p. 356) conclude that identity diffusion “seems to predispose to BPD pathology to some extent; it is associated with borderline pathology more than with any other.” Despite its theoretical centrality, identity diffusion could be a problematic criterion on which to base the borderline diagnosis in clinical practice because it is difficult to identify it accurately without prolonged observation and contact with a patient (Gunderson, 1984, p. 8). Nevertheless, a number of the most important borderline symptoms are meaningfully related to—and possibly causally rooted in—diffusions of identity. Crawford, Cohen, Johnson, Sneed, and Brook (2004, p. 383) even hypothesized, that people who experience identity diffusion might use cluster B symptoms as a form of maladaptive defense against the distress, which typically arises from a poorly integrated identity. Intimacy and engagement imply a constant threat of fusion and the loss of a fragile identity, both of which can be defended against by the symptoms and disturbed behaviors seen in borderline patients. Thus, symptoms, dysfunctional behavior and pathological thought processes are seen as attempts to cope with a diffused identity and a generally fragile personality structure.


Identity diffusion is typically manifest as having great difficulty in answering simple—but psychologically essential—questions like: Who am I? How can I be differentiated from everybody else? What do I want? How can my present life and problems be meaningfully related to my past history and my conceptions of the future? In therapy, identity diffusion manifests itself as, among other things, inconsistent, faulty and crude concepts of self and significant others, rapidly shifting emotional states and descriptions of the self that present sharp discrepancies from interactions with the therapist in the here and now. Patients with identity diffusion “may present a completely chaotic and contradictory view of themselves without awareness of the nature of the description that they convey”(Kernberg, 2004, p. 62). The normal sense of individuality and authorship over one’s own life is impaired.  An unstable and fragile sense of self and identity gives rise to an often urgent feeling of emptiness and a strong need for others to fill the inner void and give structure to reality. Presumably, the high comorbidity (40–50%) found between BPD and dependent personality disorder (Stuart et al., 1998) is partly due to this strong need for others to compensate for deficits in personal identity. In relation to this, it is noteworthy that Modestin et al.’s (1998) investigation of identity disturbance in personality disorders found the highest prevalence of identity disturbance in patients with precisely dependent and borderline personality disorders. Helene Deutsch (1965) describes how people with ‘as-if’-personalities, where identity diffusion typically is salient, pick up signals from the outer world, and mold themselves and their behavior accordingly. This high field dependency is particularly problematic if the field (social relationships, contemporary culture, etc.) is loosely structured and dominated by incoherence and instability. By adherence to a group, they seek to give content and reality to their inner emptiness and establish the validity of their existence by incidental identification with others. Similarly, Marcia (1980) has observed that people with insufficiently developed identities are more liable to change their evaluation of themselves substantially in response to external feedback. Endeavors like these to compensate for identity deficits and handle experienced inner emptiness, and the resulting dependency on others, severely inhibits the ability to function autonomously and will contribute to the borderline patient’s inauthentic appearance and apparent lack of an inner core. What people with identity diffusion, experience as important, meaningful and of value may be excessively determined by— and dependent upon—the context in which they find themselves (Yeomans, Clarkin, & Kernberg, 2002) and when they are alone life is frequently experienced as empty and meaningless. They act in caricature like ways, as they imagine someone else would act or expect them to act, rather than in a manner that is genuine.

Severe deficits in sense of personal identity and related feelings of inner emptiness often result in the impulsive and self-mutilating behaviors that are characteristic for borderline patients. Self-mutilation, compulsive socializing, promiscuous sexual behavior and various forms of misuse (of alcohol, drugs, food, etc.) are used to ward off painful feelings of emptiness and meaninglessness. The borderline patient’s characteristic unstable and intense interpersonal relationships are thus related to a similarly unstable sense of identity. Without an adequately formed, mature and reasonably integrated identity, goal-directed behavior is impaired, a consistent commitment to work is lacking, sense of direction in different areas of life is insufficient and intimate interpersonal relationships are severely disrupted. Rapid fluctuations between different concepts of identity result in corresponding fluctuations between different modes of behavior. “Overenthusiastic adherence to one philosophy can be quickly and completely replaced by another contradictory one” (Deutsch 1965, p. 266), just as goals, plans, opinions, essential needs and concepts of own character and individuality can change rapidly, resulting in unpredictable behavior. As mentioned above, the development of personal identity in late modernity is a product of personal choices and constructs and the individual no longer enjoys an a priori social recognition of his or her identity. One has to win it in dialogue with others, and this can fail. Consequently, it will be increasingly difficult for individuals with severe interpersonal problems to obtain the recognition from others that is necessary to stabilize their identity. Thus, identity diffusion and unstable interpersonal relationships mutually augment each other. In people with identity diffusion the normal capacity to maintain a stable core of self-awareness amid (physical and psychological) change, over time and across different contexts, is impaired. A normal sense of the self that is continuous through time is lacking and the person does not manage to construct a coherent narrative or life story to integrate his or her personal identity. Life is experienced as a series of essentially unrelated fragments.

Moreover, identity diffusion often manifests itself as a tendency to role absorption (Wilkinson-Ryan & Westen, 2000), a tendency to define the self unilaterally in terms of a single role or label and a rigid adherence to—in some cases idiosyncratic—norms and values. The patient attempts to stabilize his or her self by temporary hyper investments in explicitly defined roles, (fundamentalist) worldviews, value systems and relationships that ultimately break down and enhance the predominant sense of emptiness, meaninglessness, confusion and absence of stable structures and narratives to guide his or her being in the world (Westen & Cohen, 1993).

…. (Goodness I can’t tell you how many times I’ve tried to do this… though  it’s not so much an attempt to define myself solely by that thing so much as I’m trying to submerge myself in it to see if it really fits me. I try things on like a new skin, but maybe that’s just calling a tomato a tamahtoe )….

Finally, the use of projection, projective identification and other primitive defense mechanisms are motivated by the borderline patient’s need to create a coherent, continuous and stable sense of identity. Parts of the self and personal identity are evacuated in order to create a coherent (albeit illusionary) and stable identity. Despite its prevalence and significance in borderline disorders our understanding of identity diffusion is insufficient since it has been the subject of very few empirical investigations and many more theoretical works.

When Therapist first talked to me about this she mentioned something about an improperly forming ego development in the person with the Borderline pathology. As a child you grow up learning from your parents, mimicking your parents, but eventually you begin to establish your own independence… or at least you should, but sometimes things go wrong. If there is abuse or abandonment there is an interruption in the process and the child never learns to properly establish independence and a healthy sense of their own self. They only learn to continue doing what they need to do in order to maintain their survival. This is a very truncated explanation. There’s more to come though! Tomorrow is Psychological Causes! Stay Tuned! 

4 comments:

  1. Wow! You have no idea how much this article resonates with me. Someone I know and love dearly has BPD, or at least we all think she does but the stupid health system won't diagnose her!
    This article was just another one of those times that I am just blown away at how perfectly everything fits with her, it all makes sense, it's so her. Wow. It's tragic though, I don't know how she'll ever get true healing. I keep seeing these destructive patterns happening over and over again, and it breaks my heart. She doesn't deserve the pain she feels..

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  2. 'temporary hyper investments in explicitly defined roles'
    Has been my whole life cycle after cycle each ending in utter exhaustion along with either rejection or withdrawal & so much grief & pain.
    These posts are in part fairly heavy going but well worth the effort. Thank you for posting them.

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  3. Interesting article.. But what I want to know is HOW to change this. HOW do you develop a strong sense of self???

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    Replies
    1. Exactly! That's what I want to know to.

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