Borderline Personality Disorder in Girl, Interrupted
Girl, Interrupted is perhaps the most popular work in popular culture about Borderline Personality Disorder. When many persons think of BPD, they think about the 1999 film adaptation starring Winona Ryder and Angelina Jolie (perhaps confusing Ryder’s character, the one diagnosed with BPD, with Jolie’s character, the erratic but charismatic sociopath).
The film is based on a memoir of the same name written by Susanna Kaysen. The author was not a fan of the film, which added melodramatic embellishments. The book is fairly simple, detailing 18 months Kaysen spent in an inpatient psychiatric hospital in Massachusetts in the 1960’s when she was 18 years old (Kaysen, 1994).
Is BPD portrayed accurately in those works? Or does it give the public a distorted image of what it means to have BPD? The truth is the book and film don’t show much at all about BPD, or what it means to live with BPD. The primary message that comes through, however, is that BPD must be very serious, if it requires months of hospitalization. We are told our main character has BPD (though we are not told much about what this means, nor do we really see it expressed), and she is locked up with other, much more impaired individuals (occasionally seen tied down, or receiving electroconvulsive “shock” treatment against their will).
The truth is, we did not have effective treatments for BPD until fairly recently, such as Dialectical Behavior Therapy. Today, people with BPD do still end up in psychiatric hospitals, but that is often not the best decision. Before effective treatments like DBT, persons with BPD were often placed in hospitals because nothing else seemed to work, or because providers did not know what else to do. That is the situation as portrayed in Girl, Interrupted.
Girl, Interrupted, the book
Written as a series of short stories or reflections on various topics, the book opens with a meditation on the nature of sanity and insanity. Susanna begins by claiming that, when others ask about her time in the hospital, they are really motivated by a concern that something similar could happen to them. She describes mental illness like slipping “into a parallel universe,” where things are both very similar and very different. This is an important theme in the book.
Susanna tells the story of being admitted to the hospital after a short visit with a new psychiatrist. She claims it was presented to her as a short rest, lasting only two weeks, yet it would last almost two years. She includes her referral and admission paperwork. Her memories of the event as told in the story leave out the concerning details that led to her admission: confusion, suicidality, withdrawal and isolation. Perhaps these things seemed not so unusual to her at the time, though they were evident to others. This too is an important reoccurring theme.
Susanna’s symptoms included depression, “chronic emptiness and boredom,” skin picking and beating her wrists (forms of self-harm). She also described suicidal thoughts and aborted attempts, and at least one attempt that almost succeeded. While denying being “genuinely suicidal,” on one occasion she consumed 50 aspirin and passed out in public, only to awaken after having her stomach pumped. She also claims that, while she sometimes had very distorted thinking, she was always aware this was the case, and never confused these thoughts with reality.
Near the conclusion, Susanna described the symptoms of BPD and how they apply to her. She claims she did not look up “the charges against her” until 25 years later, and she is ambivalent about how well the label applies to her. She largely concedes that “it’s a fairly accurate picture of me at 18.” However, she struggles with that fact that BPD is a personality disorder, which she believes suggest some degree of “culpability” (whereas if she had bipolar disorder or schizophrenia she would have been “blameless”).
Susanna also has a meditation on suicide, including information on how to increase your chances of successfully completing it. Even years later, she seems to romanticize suicide, self-harm, and at times mental illness in general in a way that seems unhealthy, and potentially triggering for some people.
The story continues in a non-linear fashion. We do not get a description of the hospital (as if she is seeing it for the first time) until about a third of the way through the book. Characters come and go. Some we read about, only to be actually introduced to later. We are told that Georgina, a junior at Vassar, experienced “going crazy” very suddenly, as a “tidal wave of blackness.” We meet Polly, hospitalized after trying to light herself on fire, disfigured from the flames. Susanna seems oddly impressed by Polly and her “dedication" to try and kill herself, when Susanna could never bring herself to take that final step and “light the match.” Susanna smiles when she remembers Lisa (who we are told was a sociopath) because she was “funny,” as well as angry and violent. There is Daisy, who appears to be suffering from an eating disorder and OCD, who commits suicide shortly after being released. We also meet various members of the staff, including Valerie (the well-liked head nurse) and Susanna’s psychiatrist Dr. Wick.
Borderline Personality Disorder as portrayed in Girl, Interrupted
Prior to the events of her memoir, it appears Susanna was primarily being treated for depression. While in the hospital, however, Susanna was diagnosed with borderline personality disorder.
Borderline personality disorder is characterized by “A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts” (American Psychiatric Association, 2013). Susanna says the diagnostic criteria was fairly accurate, though not “profound.” She does seem to meet many of the diagnostic criteria.
For example, she alludes to “frantic efforts to avoid real or imagined abandonment” with a previous boyfriend, and she certainly seems to have some confusion around her personal identity (possibly up through the writing of her book). She exhibited “recurrent suicidal behaviour, gestures, or threats,” and at least one suicide attempt is described in detail. Her admission paperwork also notes these symptoms, though she does not mention experiencing them at the time. She describes struggling with boredom and “emptiness,” and her writing hints at experiences of paranoia. While we do not have sufficient information to make a definitive determination, it appears Susanna met criteria for borderline personality disorder.
What is Borderline personality disorder (BPD)?
Borderline personality disorder (BPD) is a personality disorder characterized by instability in several domains: affect, sense-of-self, relationships, and impulse control (Lieb et al., 2004). It affects about 1-2% of the general population, 10% of psychiatric outpatients, and 20% of psychiatric inpatients. About 70% percent of persons with BPD are female, and there are gender differences in how the disorder is expressed. About 10% of persons with BPD commit suicide. BPD symptoms tend to begin in late childhood, several years before treatment is generally sought. However, it is generally more responsive to treatment than other serious mental illness such as bipolar disorder. One study found that 75% of persons treated for BPD were still in remission at a six year follow up.
Traditionally, BPD was not diagnosed before the age of 18 (Sharp & Fonagy, 2015). There are several reasons for this, which include concerns about stigma, and that the incomplete identify formation and increased emotionality of adolescents makes it hard to determine if the disorder is present. There is now greater consensus that such a diagnosis is possible and advisable so that effective treatments can be provided earlier. However, the DSM-5 suggests great caution, and urges only diagnosing children with BPD in “unusual instances.”
BPD is defined by the DSM-5 as “a pervasive pattern of instability in interpersonal relationships, self-image, and emotion, as well as marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated” specific symptoms across at least five of the following domains: frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships, identity disturbance with unstable self-image, impulsive behavior in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating), recurrent suicidal or parasuicidal behavior, emotional instability, chronic feelings of emptiness, inappropriate/intense anger, and stress-related paranoid ideation or severe dissociation (American Psychiatric Association, 2013).
One qualitative study attempted to add more detail to this definition by asking persons with BPD to describe what thoughts each of these symptoms prompted for them (Brand et al., 2021). The results: “I hate you, don’t leave me. No one wants to stay close to me. Who or what am I? Spontaneous and risk-taking, my inner being has been hijacked. Sheer and utter hell. Get me out of here. Call back later.”
Persons with BPD face many interpersonal difficulties. According to one study 73% of persons with BPD report aggressive behaviors within the last year (Herpertz et al., 2017). This aggression is a product of both poor emotional regulation ability, as well as a maladaptive emotion regulation strategy (often supported by the environment). It appears males are more likely to be physically aggressive than females, and MRI studies suggest this is likely the result of the difference in the way male and female brains process emotional information. In addition, there is evidence that persons with BPD experience difficulty empathizing with and reading the emotions of others, due to the interference of their own emotional reactivity (Domes et al., 2009).
It has also been suggested that persons with BPD also have reduced mentalizing skills (Fonagy & Bateman, 2008). Mentalizing is the ability to accurately judge what others are thinking and feeling, in any given moment and across time. This skill is thought to develop in the context of the parental relationship, which makes sense given that persons with BPD often have histories of poor relationships with their primary caregivers.
Persons with BPD often face high levels of stigma, including from providers. Bodner et al. (2015) examined provider attitudes towards persons with BPD amongst social workers, psychologists, psychiatrists, and nurses. Nurses and psychiatrists reported more negative attitudes and less empathy toward persons with BPD. While nurses reported an interest in learning more about this disorder and how to treat it, psychiatrists reported low interest in improving their ability to treat persons with BPD.
According to Eaton (2011), while BPD consists of both externalizing aspects and internalizing aspects, the internalizing aspect seems to be stronger. Aggression and other interpersonal difficulties primarily originate in the tendency to externalize, whereas mood issues, self-harm and suicidal behaviors are issues of internalization. While these psychological features are often gendered, in BPD they appear to be less so than with other disorders.
According to the leading theory on how BPD develops, the defining feature is an emotion dysregulation deficit (Salsman & Linehan, 2012). This deficit is posited to be the product of a biological vulnerability interacting with an invalidating parental environment. Emotion dysregulation generally consists of having a higher baseline level of emotional intensity, higher levels of emotional reactivity, and the tendency to stay emotional for a longer period of time before returning to baseline (Crowell et al., 2009). Increasing emotion regulation skills tends to reduce the symptoms of BPD, suggesting that is the primary moderating factor in BPD. There is also evidence of increased physiological reactivity to emotional stimuli which seems to support this theory (Kuo & Linehan, 2009). According to a new proposed addition to the theory, emotion dysregulation tends to manifest in children primarily as impulsivity (Crowell et al., 2009). This vulnerability reacts with the child’s environment, bringing out greater levels of invalidation, heightening emotional sensitivity over time and preventing the acquisition of effective emotion regulation strategies.
Persons with BPD often present with a long history of receiving mental health treatment (Lieb et al., 2004). Almost all persons with BPD report receiving treatment (97%), from an average of six therapists. Most have tried group therapy (56%), and almost half have attempted family or couples therapy (42%). The majority report at least one hospitalization (72%), and many are described as being hospitalized “frequently” (9–40%).
Dialectical behavior therapy (DBT) is the most empirically supported treatment for BPD (Kuo & Linehan, 2009). According to Cristea et al. (2017), the only other treatment with any research support is a psychodynamic approach administered by experienced providers. They also note, however, that effect sizes were smaller when compared to treatment for many other disorders, and gains less likely to be sustained at follow up, reflecting the difficulty in treating this disorder.
Borderline personality disorder (BPD) Treatment: What if Girl, Interrupted were written today?
During her time in the hospital, Susanna undoubtedly received some sort of treatment (even if it was simply milieu treatment). The nature and extent of this treatment is almost completely omitted from the book, though we can assume it was at least somewhat successful. We can assume this because she was released from the hospital and we were not told about any further problems she encountered (such as a subsequent hospitalization). It is also possible Susanna experienced some sort of recovery that was unrelated to any treatment she received.
Susanna was diagnosed with borderline personality disorder. Today, the most commonly used evidence-based treatment for BPD is dialectical behavior therapy (DBT). This treatment did not yet exist when Susanna was hospitalized. DBT is also an effective treatment for severe depression and suicidality, so even if the BPD diagnosis was incorrect, the selection of DBT could still prove to be an effective treatment for Susanna.
DBT is a cognitive-behavioral, skills based intervention. There are four main skills that DBT clients practice and apply: distress tolerance, emotion regulation, interpersonal effectiveness, and mindfulness. Mindfulness is a prerequisite for and helps to improve the other skills, by reducing impulsivity and reactivity, which would be beneficial for the issues Susanna describes. Interpersonal effectiveness would be beneficial, as one of the primary tasks here is to learn to select better friends. Susanna’s admiration for some antisocial and suicidal persons suggests she could use help building healthier relationships. Emotion regulation is about changing one’s life in a manner that would lead to greater happiness, which anyone suffering from depression could benefit from. However, with Susanna, one would likely start with distress tolerance skills. This is because her primary presenting problem was suicidality, and she did have at least one suicide attempt. In DBT, these are considered “stage one” targets, and are always addressed first if present. One of the quickest ways of reducing suicidal behaviors is to provide alternative ways of managing intense distress.
Susanna’s first goal therefore would be to learn the distress tolerance skills. This skill would involve three objectives. First, she would need to acquire the knowledge necessary to use these skills. This would occur in a DBT skills class, and learning all of the distress tolerance skills takes about eight weeks. This involves reading, listening to lectures, and completing homework covering these skills.
Second, she would need to apply these skills to the unique circumstances of her life. This would occur in conjunction with her individual therapist, where the skills would be discussed, and Susanna would be asked to complete daily homework practicing these skills in a way that makes sense for her. The application of some skills would vary widely depending on her life, while the application of others is straightforward. For example, it is a certainty that she would be asked to complete deep breathing exercises daily for 1-2 weeks.
Third, Susanna would need to generalize the use of these distress tolerance skills to all areas of her life. Of particular importance is generalizing skills to situations of high distress. This is accomplished though the use of phone coaching. When she gets too overwhelmed to use distress tolerance skills, she would be asked to call her therapist. Her therapist would provide in-the-moment coaching on skill selection and skill use. Through this, Susanna would learn to use skills even in situations where she could not before. After some time, Susanna would be able to tolerate distress without thoughts of suicide occurring.
BPD Treatment Today
Susanna’s idiosyncratic portrait of an inpatient psychiatric hospital contains many fascinating ideas, characters, and situations. She preferred to keep the spotlight off of herself, occasionally providing us with glimpses of her internal life but leaving out the details of her everyday life. While we do lack the information to make an informed judgement, Susanna agreed that the label of borderline personality disorder seemed to fit her well. Today, we have much better treatments for BPD, and it is unlikely someone with her symptom severity would end up in an inpatient hospital for almost two years.
The research on BPD points to the progress made. It is notable how there seemed to be an explosion in the 1990’s in available research. There is an obvious pattern in the journals that tend to publish BPD related research, with a cognitive-behavioral and evidence-based bent. Both of these factors were likely driven by the work or Dr. Linehan, and the research networks that grew up around her work.
This framework also tends to naturally lead to less stigma than we find present in some of the older work concerning BPD. The psychoanalytic literature, for example, seems more judgmental, which may partially explain the judgmental attitudes we find amongst psychiatrists towards persons with BPD (which is much less amongst social workers and psychologists).
Another criticism we could make is that while the available research is primarily from a cognitive-behavioral framework, many of the hypotheses presented are slanted toward the cognitive and are not easily testable. For example, the extent of metallization failures, or the role of an invalidating parental environment interacting with vulnerable biology, are hard to operationalize, measure, and test.
While there are certainly some gaps and unanswered questions in what we know about BPD, it is almost certain Susanna would receive much better treatment today than she did in the 1960’s. Of course, it is also possible that some of the available research would not have existed had it not been for this popular and inspiring work.
