Shirah Vollmer MD

The Musings of Dr. Vollmer

Borderline Personality Disorder: Bah

Posted by Dr. Vollmer on September 19, 2016

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Primitive mental state-that is what I strongly prefer to say when my students tell me that their patient, or their patient’s mother has “Borderline Personality Disorder.” My reasons are many, which begin with I find this diagnosis misogynistic, given to women who exhibit colorful or spirited emotional responses to stress, thereby imposing a judgment in which emotional reactions are somehow pathological. I accept that women and men, as a general rule, express themselves differently, but to say that a woman who describes dark moments in her feelings a “borderline” is to inhibit the facilitation of emotional expression. Second, I find this diagnosis a way of saying that the doctor does not like the patient, and finds the patient’s emotional experience objectionable. It is as if the doctor perceives the patient in a compassionate way, then the doctor diagnoses Major Depression, but if the doctor starts to feel uncomfortable with a patient, then he/she is more likely to throw the personality disorder label on the patient. Third, the terminology “Borderline Personality Disorder” does not convey the process in which the personality needs help. I prefer the developmental model of personality in which some of us fail to develop, or we develop and then we regress to more primitive expressions of our feelings which often involve rage and bodily and/or property destruction. If we were to use the term “primitive mental state” then we convey a certain hopefulness, that with all states of mind, they are fluid and subject to maturity and emotional growth, whereas “Borderline Personality Disorder” implies a life-long struggle which borders, pun intended, on hopelessness.

My students, taught this diagnostic system, are almost always taken aback by my objection to our language, which shapes our thinking, and hence our interventions. The advantage of a big institution, like UCLA, for example, is that students are exposed to multiple ways of approaching this complicated organ, we refer to as the brain. This seems to give little comfort, when I encourage them to challenge their rock stars. Students, like patients, have a transference to their teachers, and so learning new information, in such an intimate setting, is not an emotionally neutral experience, but rather it is an experience filled with identifications and defensiveness. Therein lies my challenge. I need to work with both the conscious and unconscious aspects of my student’s brain, while at the same time, not go too deeply into their own personal dynamics. Like psychotherapy, this is a delicate dance, which most of the time goes well, but occasionally I need to be mindful, not only the layers in treatment, but the layers in teaching as well.

5 Responses to “Borderline Personality Disorder: Bah”

  1. Shelly said

    From this blog, I gather that Borderline Personality Disorder is not a real disorder or diagnosis but a label, a term to describe someone who causes the physician too much trouble or bothers them too much or is simply a pain in the neck. It sheds light and validates a fear that patients have of sharing their deepest pain with their doctors or as being seen as “too real.” Even your politically-correct term as being “in a primitive mental state” is no less demeaning to these patients. Why do you call them “primitive?” Because they can’t seem to get a handle on their emotions? Because they are real and that is not socially acceptable? I also think by giving your patients labels like these, it allows the physicians to place distance between themselves, the “healthy ones,” and their patients, the “pain in the neck” ones. Unless of course the physicians become the patients some time.

    • Hi Shelly..our diagnostic system is flawed and as such many, but not all, of our diagnoses become labels, rather than windows into understanding psychopathology. I did not intend “primitive mental state” to be politically correct, but rather I was trying to convey that behavior runs on a spectrum of maturity, and under stress, or having experienced trauma, then, as human beings, we mentally regress to a lower level of thinking, which means we are more reactive and more self-centered. There is no question that physicians work hard, both consciously and unconsciously to try to tell themselves why they will not suffer as their patients are suffering, but at the same time, working intimately with patients, brings up our shared humanity, and the deep connection that we all share common feelings and struggles, while we navigate the stressors that our thrown our way, either randomly, or engineered by our decision making. The dynamics between patient and physician, particularly when the patient is a physician, interests me deeply. Working with these dynamics, is working with the transference and countertransference, and hence the work is both endlessly interesting and almost impossible to teach. Thanks.

  2. Ashana M said

    Primitive mental state is terribly dehumanizing.

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