Beatrice Dalle in Betty Blue is the poster girl for borderline personality disorder (BPD). She was pinned up on student walls the world over in the late 1980s and early 1990s; often by the sorts of men who were always complaining about being harassed by crazy women, or by the sort of women who had become resigned to that sort of classification.
A Betty is fun at first. She’s the volatile woman on the cover of pulp novels who smokes reefers, brandishes flick-knives, and gets her blouse torn off. She has kohl-smudged eyes, a great home-hacked fringe, swigs whisky from the bottle, wears artfully trashy underwear and drops her ash in the bedsheets, occasionally setting fire to the house.
But she becomes a drag. She suffers mood swings, obsessive thoughts and violent outbursts. Look closer and there’s a litany of fine lines up her arms from broken wine glasses and razorblades. Her drug use spirals out of control, and the sex becomes stalky. She’s an attention-seeker, a drama queen, a chaos merchant, a slut. She’s the kiss-and-tell mistress. She’s the girl who stitches up defenceless football coaches. Maybe, briefly, someone with a Betty fetish will try to fix her, but eventually she just becomes another crazy-bitch anecdote.
Men can be diagnosed, too, but BPD has come to represent a certain type of woman in the public psyche: Winona Ryder in Girl, Interrupted; Demi Moore in St Elmo’s Fire; Uma Thurman in Pulp Fiction; Jennifer Jason Leigh in Single White Female; Emily Lloyd in Wish You Were Here; Vivien Leigh in Gone with the Wind. At least, these are the characters that the armchair experts of the internet have diagnosed in forums over the years. In short, BPD has become the buzz term for unruly females.
Thing is, it’s a construct. While BPD has been pathologized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a disorder – with a three-to-one female-to-male ratio – it’s more accurately a suite of coping mechanisms. Its behind-the-scenes nickname, in fact, is “hard-life syndrome”.
In her book Cognitive-Behavioral Treatment of Borderline Personality Disorder, Marsha Linehan cites various studies of BPD patients to conclude that 67 per cent to 86 per cent had experienced childhood sexual abuse. Other common drivers are neglect, a break in parental bond, and witnessing violence or abuse, while some theorists argue there’s a hereditary aspect. To be diagnosed, an individual needs to meet five out of nine criteria that include: frantic efforts to avoid real or imagined abandonment; unstable interpersonal relationships; unstable self-image; impulsivity; suicidal behaviour or self-harm; reactive moods; chronic feelings of emptiness; difficulty controlling anger; and paranoia or dissociation.
Historically women who step outside the boundaries of idealized femininity are given a label. It’s a way of regulating women
How do you reckon people deal with those kinds of feelings? That’s right! Self-medication. Two-thirds of people with BPD will develop problematic use of substances at some point in their lives, making it the personality disorder with the second-highest substance use prevalence, after the more male-associated antisocial personality disorder.
So is it time to ditch the label? Professor Jayashri Kulkarni thinks so. She’s the director of the Monash Alfred Psychiatry Research Centre in Melbourne.
“The term ‘borderline personality disorder is derogatory,” she tells me emphatically. “It demeans everything. It loses the connection with the early trauma, whereas at least if you call it ‘complex trauma disorder’, as we do here, you force clinicians to think, ‘Hang on, did I ask about that?’ The consumers are catching on to that term, but to get it catching on more widely I feel as though we need campaign buttons.”
It’s a sentiment echoed by Professor Jane Ussher from the Centre for Health Research at Western Sydney University. “Some people have described BPD as a dustbin diagnosis,” she says. “Women who are ‘difficult’ or resistant might be diagnosed as borderline today. If you look at a woman’s history and she has experienced sexual or physical abuse, calling her ‘borderline’ pathologizes it. It says to women they’ve got an illness, rather than their reaction is understandable.”
Ussher thinks having a historical perspective is important when considering this pathologization of women. In the nineteenth century, inconvenient women could be committed to asylums by their husbands for reasons such as postnatal depression, or being infertile, or simply to make way for a new affair. It would take one doctor’s signature to have a woman committed, but three signatures for her to win her freedom – an impossibility.
“Women have always been positioned as mad,” Ussher says. “What we can see historically is women who step outside the boundaries of idealized femininity are given a label. It’s a way of regulating women – if you cross that boundary there are going to be consequences in how you’re going to be seen, how you’re going to be treated.”
What additionally fires Ussher up is that there’s a profit to be made in making BPD a diagnostic classification. According to the research of Dr Marcia Angell, writing for the New York Review of Books in 2011, about one-fifth of the funding of the American Psychiatric Association – which puts out the DSM – comes from pharmaceutical companies, and more than half of all the taskforce members of the fifth edition of the DSM have significant industry interests. Ussher explains, “We’ve got a circular problem here. It’s the American Psychiatric Association that devises all these diagnostic categories and creates new ones every time they have a new DSM. They decide the symptoms, from which people – primarily women – are diagnosed, which then creates a market for these drugs.”
We have all these sentimental feelings for little children who are being abused and hurt, but then we don’t accept what happens to them when they grow up, when they display antisocial behaviours
There’s also a gender bias to take into consideration. Marcie Kaplan noted in a 1983 article in American Psychologist that the experts on the DSM taskforce were mostly men who had codified their biased assumptions about what behaviours were healthy in a woman and what were not. And seven years later, in his book Sex Differences: Modern Biology and the Unisex Fallacy, veteran biologist Yves Christen called the DSM “a masterful piece of sexism: it takes gender into consideration, in that its definitions of psychological normality differ for men and women”.
All of this doesn’t bode well for the woman seeking professional help. Professor Kulkarni describes stories she’s heard of women being traumatized further by going to the emergency department after a suicide attempt and being treated badly. “This is a patient who will present sometimes with mania, sometimes depression, sometimes dissociation, sometimes with brief psychotic episodes,” she says. “On the one hand, this is a very difficult person to manage; on the other hand, the health services are not looking for the whole story. Doctors and mental health services only see the end product: ‘Here’s the nineteen-year-old who’s turned up yet again with a drug overdose or Panadol overdose, wasting our time. Is she really trying to kill herself? Well, why the hell doesn’t she do it properly?’”
That’s echoed by Dr Ben Sessa, a Bristol-based child psychiatrist who also conducts clinical trials in MDMA-assisted psychotherapy with his alcohol-dependent adult clients. They’re twin interests, in his view. “We have all these sentimental feelings for little children who are being abused and hurt, but then we don’t accept what happens to them when they grow up, when they display antisocial behaviours. It’s a sloppy understanding of developmental psychology,” he says.
Sessa gives the example of visiting a fifteen-year-old girl in casualty after she’s taken an overdose. “The nurses will say: ‘Don’t let her get one over you; she’s a manipulator, an attention seeker.’”
One significant problem for doctors is that there are 256 different presentations of BPD – because there are that many combinations of the diagnostic criteria. No wonder it’s easier to put a patient on medication and move on – or maybe five different medications. “They get an antipsychotic, an antidepressant, a mood stabilizer, a benzodiazepine tranquillizer, then they might be doing their own drugs and alcohol,” says Kulkarni, “and it’s a bloody débâcle because each of those has side effects. Think about the intermittent disruption to the brain – the biochemistry and circuitry. Then there are the intermittent stresses that will disrupt everything, and then there are substances that will trigger everything. By the time someone thinks, hang on, maybe there was something in their early life that we should be dealing with in a psychotherapeutic sense, the person is in a complete mess.”
The good news is that Professor Ussher believes that, unlike some disorders, BPD certainly need not be a lifetime companion. “Say I had a diagnosis of BPD,” she says, “in five years’ time I might not be exhibiting those behaviours, and that might be for a whole range of reasons. I might have had good therapy and learned healthy coping mechanisms. My living situation might have changed. I might have got in a really good relationship – we know that positive relationships are a really good protector of mental health, for both men and women. What we know for sure is that the greatest ‘cure’ for a whole range of psychological disorders is time.”
To this, I can add the comforting thought that it’s been decades since I last hurled a missile at someone and stormed out to sleep on the pavement (a resolve that only tended to last half an hour, but hopefully long enough to make someone worry). And years and years since I last came in from a long evening of alienating a group of people, furiously sank a cider at the kitchen table and headed out again to see if I could catch last orders and ostracize myself from another group.
Thank god, too. It was exhausting.
This piece was extracted from Woman of Substances by Jenny Valentish, published 17th May 2018, £16.99 (Anima, an imprint of Head of Zeus)