Paul Golden, MD Speaks; Depression & Bipolar Disorders
“Opening the Black Box on Mental Illness” Seminar, part I: Depression & Bipolar Disorders and…
Part 4 – Borderline Personality Disorder
When I first read “Girl Interrupted” I was confused. She is in a taxi to a mental hospital. Her two week hospitalization became 18 months. This is an autobiography about her stay in the McLean Psychiatric hospital in Cambridge, Massachusetts from the 1967 to 68. She wrote this in 1993. (Vintage Books, 1993. The description of her symptoms for this diagnosis confused me as they did not include what I thought were those of any mental illness and I was not familiar with the other ten major personality disorders.
I looked in my floor to ceiling bookcase (with a sliding ladder) but could not find it so I ordered another and just read it for this piece. The pertinent parts I present here.
At the beginning is her admission form. She was admitted April 27, 1967. She is described as Jewish, single with no occupation. Her father worked at the Princeton Institute for Advanced Studies as its Director. And the family home was in Princeton, New Jersey as well.
The admitting diagnoses were: Psychoneurotic depressive reaction. Personality pattern disturbance, mixed type. R/O Undifferentiated schizophrenia. Established diagnosis prior to the above was borderline personality. Prior hospitalizations Auburn Hospital, Cambridge, Mass. 1965 (stomach pumped).
Her roommate was Georgina who was admitted during her junior year at Vassar after a psychotic episode at a movie theater.
Susanna had an appointment with a psychiatrist she had not seen before. He noticed that she had been picking at a pimple. When asked if she had a boyfriend (yes) he basically told her she was having trouble with him. At which point he tells her “You need a rest.” She is tired from getting up early to take two trains to get to the appointment.
While the doctor is off to another room Susanna is thinking, “I have thought often of the next ten minutes—my last ten minutes. I had the impulse, once, to get up and leave through the door…walk the several blocks to the trolley stop …that would take me back to my troublesome boyfriend, my job at the kitchen store. But I was too tired.”
When the doc returns he tells her, “I’ve got a bed for you. It’ll be a rest. Just for couple of weeks, Okay?”
He states she’ll go Friday to which “He bore down on me with his belly. ‘No. You go now.’ It was Tuesday…”
Then is, to me, the infamous taxi ride. “He (the psychiatrist) took me by the elbow…he opened the back door of the taxi and pushed me in…and slammed the door; shut”. After the taxi driver asks where to, the doc says “Take her to McLean and don’t let her out till you get there.”
With her is the doctor’s hand written form for the admissions people. Pertinent are that it is 4/27/67, 18 years old, that her father’s income is “enough for a yr.—50,000 income assets 60-70,000 dollars.” The reason for referral he wrote, “Profoundly depressed – suicidal, increasing pattern less of life, promiscuous, might kill herself or get pregnant, ran away from home 4 months earlier, living in boarding house in Cambridge—Desperate. I might add that the doctor’s visit was all of 15 to 30 minutes!
I record all of this because it supplied the meat of what appears to be exaggerated diagnoses and monetary reward for an unspecified but stay as long as a year. The taxi ride is what after 26 years is what I remembered the best.
In his record of his office visit, written June 15, 1967 (two months later), he wrote “Susanna Kaysen was seen by me on April 27, 1967; following my evaluation which extended over three hours, I referred her to McLean Hospital for admission. My decision was based on…” In summary he wrote, chaotic unplanned life of the patient, progressive decompensation, reversal of sleep cycle, severe depression and hopelessness and suicidal. He goes on to say Susanna is ”immersion in fantasy, progressive withdrawal and isolation” and is careful to say that prior to ever seeing him Susanna had been in psychotherapy but not with him. He emphasizes that he has never seen her before.
As an aside Susanna reveals her suicide attempt with pills from two years earlier, 1964. “I had an inspiration once. I woke up one morning and I knew that today I had to swallow fifty aspirin.” She survived because she went into the street to walk to her mother’s place of work to tell her and passed out. “…but going onto the street and fainting is like putting the gun back in the drawer.”
Mclean was a hospital that had housed many famous people including Robert Lowell, James Taylor and his siblings, Kate and Livingston, Sylvia Plath, Ray Charles and others. Susanna writes this fabulous line: Did the hospital specialize in poets and singers, or was it that poets and singers specialized in madness?”
Georgina’s boyfriend, Wade. “He was enraged about almost everything and glowed with anger. Georgina explained that his father was the problem. His father is a spy, and Wade’s mad that he never would be as tough as father….Wade’s father had two friends who particularly impressed Wade. Liddy and Hunt.” (Watergate burglars).
Susanna has a chapter on suicide in general. “Suicide is a form of murder—premeditated murder…I think many people kill themselves simply to stop the debate about whether they will or they won’t.”
Susanna felt alienated from people, “…when you look at a face, you see a blob of rubber because you are worried that your face is a blob of rubber.” (Disassociating?) Although wondering if she was mad she quickly debunks that. “My ambition was to negate. “The world, whether dense or hollow, provoked only my negations.” She pretended to live opposites. When asleep she felt she was awake and when speaking she felt she was being silent.
Some psychosis? “The checkerboard tile floor of the ice cream parlor certain patients were taken across the street bothered Susanna. The black and white squares meant to her, “Yes, No, This, That, UP, Down, Day, night—all the indecisions and opposites that were bad enough in life without having them spell it out for you on the floor.”
The routine of a psych ward that I hated as did Susanna were night time checks. Flashlights every 30 minutes, no sharp objects, no belts (we all lost weight and the staff would cinch up our pant loops with zip ties. Besides no belts you are not allowed sweat pants or tops with cords! Hang oneself with these?! Plastic eating utensils and I could go on and on. A psych ward is supposed to be a “safe place” and yet I felt anything but with all these restrictions and being housed with out of control schizophrenics, anger disorders, sociopaths, drug detoxers etc.
I love the lines, “Insanity comes in two basic varieties: slow and fast. I’m not talking about onset or duration. I mean the quality of the insanity, the day-to-day business of being nuts.”
And, oh my, Kaysen writes about one particular obsession—the positon of her tongue in her mouth. This was exactly one of my obsessions during my OCD years in elementary school!
Other obsessions or ruminations she puts this way: “These thoughts have no meaning. They are idiot mantras that exist in a prearranged cycle. I’m no good, I’m the Angel of Death, I’m stupid, and I can’t do anything. Thinking the first thought triggers the whole circuit. It’s like the flu: first a sore throat, then, inevitably a stuffy nose and a cough.”
Here is the ultimate tool used on Susanna: “The only power they had was the power to dope us up. Thorazine…the therapist’s’ friends. The resident could put us on that stuff too, in an ‘acute’ situation. One we were on it, it was hard to get it off. A bit like heroin, except it was the staff who got addicted to our taking it.”
“I began scratching at the back of my hand. My plan was to get hold of a flap of skin and peel it away…”
Upon seeing a new therapist, Melvin, Susanna says to Lisa, “He’d flattered me—he understood me well enough to know I craved flattery—and in gratitude, I acquiesced.”
The last twenty pages are Kaysen’s take on borderline personality disorder from a perspective of twenty years later.
According to the National Institute of Mental Health borderline personality disorder includes varying moods, self-image obsession and other abnormal behaviors. The result is impulsivity and problems with relationships. Anger, depression and anxiety for varying periods of time is a particularly large problem.
They tend to think in black and white. Another may be completely a friend or completely a foe with no in-between.
An article by NAMI states that 1.6% of the adult U.S. population has borderline personality disorder but that may be an underestimate with some suggesting 5.9%. If that is the case the number is three times higher than bipolar I and II combined, thus accounting for the higher than expected suicide rate in this disorder. 75% are women.
I am not going to discuss causes and therapies as I see it is fluff.
Hopefully from Kaysen’s book one can see pieces of the list of diagnostic criteria seen in this article. My take is we are borderliners` to some degree and we can see full blown borderliners among friends or family!
The other book I read is I Hate you—Don’t Leave Me. This is considered the holy grail of books about Borderline Personality Disorder. First published in 1989 it was updated in 2010. The book is by Jerold J. Kreisman, MD, and Hal Straus. I found the first half to be educational. The last half was psychobabble.