סכיזואידיות וגבוליות

Schizoid and Borderline Personalities: Can two walk together except they are agreed?

Tsvi E. Gil, B. Sc., M. A(1, 3),  Jennia Vilinsky, M. S. W (1),

Anna Iofan,  M. A., M. S. W. (2,3)., and Juan Bar-El, M. D. (1)

(1)  Community Mental Health Clinic, Fligelman ('Mazra') Psychiatric center, Acre, Israel

(2)  Community Mental health Clinic for the Youth, Haifa

(3)  Annafa Institute for Psychotherapy, Haifa

tsvigil13@gmail.com, jenyvil1@live.com, anna.iofan@gmail.com, drbarel@yahoo.com

ההרצאה ניתנה בקונגרס העולמי השביעי של החברה העולמית לפסיכיאטריה דינמית, סט. פטרבורג, רוסיה, מאי 2014

In this article we would like to introduce the notion that schizoid and borderline personality disorders emanate from a common underlying structure.  While this idea does have some precursors in professional literature, it apparently diverges from daily common sense, as well as from formal psychiatric formulations.

Daily perception of schizoid people views them as introverted, lonely, and emotionally suppressed, in addition to their other associated traits and characteristics, like indifference to praise or criticism, lack of interest or ability for social and intimate relationships, and so on.  Borderline people, on the other hand, are perceived as extroverted, emotionally stormy, with variety of superficial relations, as well as having diffused identity, impulsivity, acting out, self destructiveness, and a lot of aggression. The DSM5, representing the up-to-date psychiatric nomenclature (American Psychiatric Association, 2014) counts schizoid personality in the Cluster A (the ‘weirdos’) personalities, together with paranoid and schizotypal personalities, while borderline personality is grouped together with the antisocial, histrionic, and narcissistic personalities in the Cluster B, the ‘emotional’ personalities. Continuing for a while with the DSM definitions, it describes the essential feature of the schizoid personality as a pervasive pattern of detachment from social relationships and a restricted expression of emotions in interpersonal settings.  The DSM goes on to portray the schizoids as lacking desire for intimacy, seemingly indifferent to opportunities to develop close relationships, and not deriving much satisfaction from belonging to social groups.  As concerning the borderlines, the DSM describes their essential feature as a pervasive pattern of instability in most domains of life, including interpersonal relationships, self-image, and affects.  Worth mentioning, the DSM marks as the first criterion for diagnosis of borderlines ‘frantic efforts to avoid real or imagined abandonment’.

The Psychodynamic approach to psychiatric diagnoses (PDM, 2006) relates to borderline as a ‘megastructure’, a personality organization which transects all personality pathologies.  Borderline, according to the PDM, is characterized as having difficulties in relations, in capacity for emotional intimacy, problems with work, mood swings and anxiety, and destructive behaviour toward self or others. Schizoid people gain the diagnosis of  personality disorder, in which they are described as “highly sensitive and reactive to interpersonal stimulation, to which they tend to respond with defensive withdrawal…they easily feel in danger of being engulfed, enmeshed, controlled, intruded upon, and traumatized, dangers that they associate with becoming involved with other people”.

So far it seems we are having two personalities who lie in the extremities of the personalities scale.  And indeed, some authors, e.g. Theodore Millon (Millon, 1984, 2004), had related to them as such, claiming they have no overlap among them.

However, some other authors thought differently.  But let us first make a very quick survey of the history of the birth of these two concepts.  The term schizoid is thought to be offered by Eugen Bleuler (Bleuler, 1908), the famous inventor of the term schizophrenia – and the similarity of the two terms is not incidental, since Bleuler had seen them as points on a continuum, resemble in their predisposition to inner, surreptitious life, and occasionally glitch to distorted modes of thinking.  The relation of schizoid personality to schizophrenia is not unequivocally clear to date, however in our opinion schizoid personality is not commonly a prodromal to an onset of schizophrenia, but is rather a distinct personality type stands for its own, and characterizes the person from his or her early adulthood, as the DSM formulates.

Borderline personality had entered the psychiatric dictionary later, in 1938, (Stern, 1938) as a desperate trial – as we see it – to term hard-to-treat patients.  In a vicissitude of fate, frustrated therapists had described a class of patients characterized by their intolerance to frustration…  Since the commencement of this term as a nosological entity, there had been accumulated an incredibly vast amount of literature about this term – a phenomenon that indicates, in our opinion, the uncertainty of the professional community when relates to this term.  Put it shortly and straightforwardly, we are having grave difficulty to comprehend what borderline personality really is.

And not that we did not try.  Reviewing the history of the concept of borderline is much beyond what we are able to do in this lecture, so we will very briefly summarize some of the leading theories about borderline:

One approach sees the borderline as a distinct psychiatric entity, which putatively has biological origins. This approach fits best the formal psychiatric position, as articulated in the DSM(see for example Herpertz et al 2007, Hughes et al 2012).

A psycho-analytic structural approach, best described by O. F. Kernberg, sees the borderline as a personality organization, characterized by so-called primitive defenses, and consolidated around a failing in proper internalization of object relations (see, among many other references, Kernberg, 1970).

Another approach views borderline as an affective disorder – a chronic pattern of mood instability(see for example Akiskal, 2004).

Still another approach sees the borderline as the sequel of a complex and prolonged trauma in crucial developmental phases in childhood (Herman, 1992).

The self-psychology school of thought tends to view the borderline in terms of developmental emotional deprivation, rather than a continuous struggle with a conflict around aggression, as may be inferred from a Kleinian point of view (Adler, 1981).

A related, inter-subjective approach views the borderline not per se but as contextual, mostly a manifestation of frustration emanates from lack of empathy in meaningful relations (Brandchaft  & Stolorow, 1984).

A neuro-developmental approach views borderline as a disturbance (most likely innate) in the capacity for emotional self-regulation (Schore, 1994, Hughes et al 2012 )

Finally, we may mention an attachment related approach (one which is close to our approach, as we will portray below) which perceives borderline as a disturbance in early attachment.  This disturbance is thought to create maladaptive bonding patterns which accompany the patient for most of his or her life, and is expressed in the habitual ways the patient handles his or her adaptation to his or her human surrounding (Fonagy, 2000).

One may easily see that those approaches do not necessarily contradict or exclude each other, and there may be some overlap or complementarity among them.  Allan Schore’s ‘socioemotional’ theory, for example, is a 'neuro-psychoanalytic' theory, and combines a hypothesized brain innate hypersensitivity to a failure in caregiver’s approval. Goldstein (1996) tries to combine the structural to the self-psychology approaches, showing that borderline can be viewed as both suffering from a developmental deprivation as well as from essential conflicts.

Relying on those theories some models of treatment have been developed.  Treatment, albeit important, is not in the focus of our present lecture, although the relation between a theoretical understanding of a phenomenon and its treatment is more or less self-evident.  Kernberg’s structural, object relation theory of borderline, had yielded to a Transference Focused Therapy (TFP) (Yeomans et al, 2002).  An abstraction that puts the difficulty in mentalization as the core problem of the borderline, derived from attachment theory, had yielded to the development of Mantalization Based Treatment (MBT, Bateman and Fonagy, 2006)).  Dialectical-Behavioral Treatment (DBT, Linehan, 1993), although developed from non psychodynamic thinking, seems to rely on socioemotional view, where a hypothesized biological congenital sensitivity is presumed to gain not enough validation from caregiver environment.   Jeffrey Youngs’ Schema-Focus-Therapy (Young et al, 2006) is another therapeutic approach which had been derived from the cognitive school of thought; however it hypothesizes that borderline pathology originates from so-called ‘toxic childhood experiences’, a term relates mainly to attachment failures.

Back to the schizoid. In spite of its seniority it did not gain a list of abbreviated therapeutic models.  One cannot avoid being impressed that schizoids are not as sexy as the borderlines – well, indeed, schizoid people with their flattened affect and emotional detachment are less touching when compared to the emotional, charming, and stormy borderline.  However along the years some momentous literature had been accumulated.  The main insight we may gain from this literature is – surprise! – that the problem of schizoids is not that they do not need interpersonal relations.    On the contrary – they do gravely need! Their tragedy is that they are afraid of such relations.  They are often highly vulnerable, which may lead to the hypothesis that a traumatic hurt is an essential part of the aetiology of the schizoids (Kohut 1971, L’Abbott, 2005). But we will come to aetiology soon.

The core of being schizoid is the superiority of the inner world over the external one (Khan, 1960).  It should be emphasized, though, that this superiority of the inner world is not identical to reality misjudgment. In fact, we believe that schizoids only rarely loose their reality testing.  On the contrary, schizoids typically develop an external mantling showing an almost complete normality, as Helen Deutsch (1942) wrote, which might bring to mind her concept of ‘as if personality’ or Winnicot’s ‘false self’ (Winnicott, 1965).  Schizoids invest much in an adaptation to their surrounding, an adaptation they need – one may say – in order to ‘take them (other people) off their back’ and to enable them (the schizoids) to preserve their inner world intact.

When hypothesizing the developmental origin of the aetiology of the schizoid personality one may find a surprising resemblance to that allocated to the borderline.  Most authors in the field, amongst are Wilhelm Reich (1933), Silvano Arieti (1955), Melanie Klein (1975), WRD Fairbairn (1952) and his disciple Harry Guntrip (1969), Masud Khan (1960) and Salman Akhtar (1987) – to mention only a few – agree (with minor variations in formulation) that schizoidity is likely to origin from emotionally unsatisfying relationship with the parents, mainly the mother, in crucial, early phases in the toddler development. The child-to-be schizoid soon learns to split from his or her unbearable external world, and to build an inner world of fantasies. As Thomas Ogden (1989) formulated it, "the schizoid patient mostly withdraws from object relations with external whole objects toward an inner world consists of conscious and unconscious relations with internal objects". Since this inner world is almost always more satisfying than the external one, it regains stability over maturation.

Now, when we group together the little we have gathered so far, we may propose the common underlying mechanism – or dynamism, as H.S. Sullivan might have called it – which unites the borderline and the schizoid.  This is a disruption in attachment.  This notion could be traced in some existing literature.  Kernberg (1970) perceived the schizoid as the underdeveloped level of the borderline personality organization. Both Grinker (1968) and Plakum (1985) thought the two diagnoses are essentially in proximity. Kerbnerg (2004) suggested that both the schizoid and the borderline represent the ‘pure’ personality disorders, organized around a single fixation from the separation phase of development, and both use splitting as the main mechanism of defense.

Our theory goes as follows: The little child lives in a parental environment which is not good enough for his or her emotional needs.  This environment is insensitive, invalidating, not empathic and not containing (or holding, depending on the theoretician you favour).  As a consequence, the child splits his or her inner life from the external, unbearable reality.   Splitting means that the actual ties take place only to parts of the object, not to its whole.  By objects here we mean all constituents of the individual’s world one is to perceive, introject, and relate: significant others, self, abstractions, ideas, interests, joys and sorrows.  The child soon learns to relate to them only partially, preserving within him or herself some intact, phantasized version of them.  The relations which take place in the real world, though, are only parts, fractions, or shadows of the real objects.  The relations thereby created represent a maladaptive style of attachment, which means that the ways the individual developed for the task of connecting to objects in the world are not as efficient as should have been providing harm to the primary attachment would not have taken place.

Beside the well-known attachment styles – anxious, avoidant, ambivalent or disorganized – which may determine the ways of relating a person would execute  when grows up – we would like to bring up here Sydney Blatt’s concept (see, among many Blatt’s publications, Blatt, 2008) about two personality configurations, which he called ‘anaclitic’ and ‘introjective’. The first is centered around interpersonal (or object) relations, the second is centered around issues of self-definition. When relating to the schizoid and the borderline we hypothesize that they oscillate on the axis that lies between this two configurations.  That means that each individual can be situated on a certain point on the anaclitic – introjective axis, or the person itself may oscillate, in times, depending on inner rhythm or external circumstances, on that scale.  People may be diagnosed in formal psychiatric or psychodynamic terminology as schizoids or borderlines, but in essence the core of their personality dynamics may be rooted in either striving for relations, leaving behind the consolidation of their identity, or the other way around, namely, they neglect the development of their inter-personal skills for the sake of a more firm and reassured self.  Alternatively, the individual may defend against difficulties in interpersonal relations by sticking to a rigid or stiff identity consolidation, or another individual (or probably the same one in different circumstances or other phase in life) defends against a sense of loose psychological skeleton by investing in hasty relations.  The richness of variations seems to be obvious.

Worth mentioning here that the psychodynamic diagnostics system (PDM, 2006) perceives the schizoid as laying “firmly” at the introjective pole, namely, engaged with self-definition rather than with relations

 We argue here that the nature of the personality configuration one develops largely depends on the nature of the environment one has in one’s early childhood, the one which contributes to the ways the child copes with the developmental obstacles the child encounters.    The nature of interpersonal environment the child posses, interacting with the child’s constitutional attributes, influences the attachment patterns the child develops.  A child may be cathected to his or her self-definition, to the molding of his or her identity, on the account of developing adaptive interpersonal relations.  On the other way around, such a child may invest in interpersonal relations, striving to acquire affiliation, recognition, appraisal and so forth, at the expanse of developing a solid self-identity.  And when tackling the task of fulfilling his or her object relation needs – namely, creating meaningfully satisfying interpersonal relations – ones' patterns may be situated on the continuum which moves from a withdrawn and avoided to superficial and chaotic nature of relations. The individual may internalize one’s needs or may externalize them.  The one we call schizoid puts inward his or her drama of life, the one we call borderline puts his or her drama of life outside, in the interface between oneself and one’s surrounding. The schizoid creates a hypothetically rich, complex, vivid and emotional matrix of figures, all within his or her soul, invisible to outer observers, hereby protected against invasion, intrusion, or hurt.  The one we call borderline copes with similar task – creating a satisfying interpersonal environment. Since he or she does not know how to make it, his or her interactions are often chaotic, impulsive, hastily constructed and deconstructed. He or she experiences a lot of rapidly alternating expectations and yearnings, disappointments and disavowals.  He or she is often frustrated, and acts out his or her frustrations, in ways which we perceive as aggressive and call them ‘acting out’.   He or she fights over gaining success in relations, very often in vain, and reacts to failures with rage.  Inside him or herself he or she is afraid of being abandoned, being rejected, being alone. And here he meets the schizoid!  The schizoid is already alone.  He defends him or herself from this distasteful vicissitudes by withdrawing from the very external interactions the borderline fights over. The schizoid does not fear abandonment – he ‘runs forward’ toward it.  While the borderline fights over achieving some fulfillment of human object drives, the schizoid achieves them in his or her phantasy life.  While the borderline is frustrated for real failures, the schizoid restrains from them.

Clinicians can now gain some understanding of observed phenomena.  The schizoid suffices him or herself, while the borderline, lacking this aptitude of self-sufficiency, experiences emptiness. When tackles frustrations in meeting real world the schizoid withdraws or dissociates, while the borderline becomes depressed or destructive.  We claim that all those behaviours, while differ phenomenologically, emanate from one common source – the desperate efforts to create and retain satisfying meaningful relationships; to fulfill the need of object relations.

The Concept of Personality:

 The DSM (American Psychiatric Association, 2014) relates to personality disorders as “enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”  The emphasis on endurance and constancy is not to be missed. However, it was not always like that:  the notion of personality disorders is not as self-evident as one might assume.  Freud had not dealt with personality typology, since his conceptualizations were concerned with mental dynamics – the ego deals with the reality requirements, the id demands, and the superego dictates.  The concept of personality (or character, as it was named from the outset), has emerged as an attempt to propose a psychodynamic typology of stable patterns of human behaviours.  However, attributing a particular personality to an individual implicitly puts aside one’s context, one’s environment.  We propose that the concept of personality and personality disorder should be more dynamic, interactive, and contextual. Personality by its nature is not necessarily firm and consistent, but also fluid and changeable.  We meet the personality on the background of certain relations (often inside the therapeutic relations), and it might be different when met within other relations (Jordan, 2004).  Stone (1993) thought that the term personality related to the aggregate of modes in which we relate to our human environment. Accordingly, accomplishments and failures are to be perceived as outcomes of relations, not of inner stable constructs.  Those relations may consequently be experienced as benevolent, containing, constructive, and alternatively as not empathic, not containing, neglectful or abusive. Such relations may nurture the personality or pathologies it.  According to Blatt (2008) the two axes in which the personality operate and is typified along life – the anaclytic and the introjective – are mutually and reciprocally interacting, defending and compensating for each other, thereby creating variable contingencies. L’Abote (2005) claimed that personality and psychopathology should not be conceived as intra-personal process but rather as inter-personal, carried out especially in intimate milieu.  L’Abote proposed, therefore, to change the common term of ‘personality development’ to the term ‘personality socialization’. The subject of this approach is not merely the mind nor the behaviour, but rather the relations. Brandchaft and Stolorow (1984), mentioned above, even suggest that borderline may be an iatrogenic diagnosis, generated within therapeutic relations which are not empathic enough to suite the patient’s susceptible needs. Borderlines, therefore, is not an independent pathology but an inter-subjective phenomenon.

Diagnoses are often ways of labeling phenomena rather than understanding them.  Present day nosology tends to rely mainly on observable patterns of behaviours.  It does not take into account, at least not to a sufficient degree, in our opinion, the underlying mechanisms that create those behaviours. Also, it does not always consider the interpersonal and situational context in which those behaviours take place.  Our explanation as set down above tries to explain observable behaviours, traits and habitual patterns, in terms of attachment patterns which hypothetically derived from relevant developmental environments.

Due to limitation of our scope we have not got trough other factors we sense to be relevant, such as the ways borderlines and schizoids respond to psychological and psychiatric treatment, and the transference-countertransference matrix.  Probably worth mentioning that not all schizoid people are the same, as well as not all borderlines.  Patients in real world do not really distribute according to diagnostic systems. We propose that when one takes a close and profound look at the phenomena under investigation one reveals that these personalities  - namely, the schizoid and the borderline – are not divided to ‘eccentric’ versus ‘emotional’; What is really there – we suggest  – is their divergent ways of coping with the intricacies they meet in their shared need for engagement with human touch.

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