Question:
I have BPD, but have split off the unacceptable parts of myself (i.e., the rage, sexual urges, neediness, abandonment stuff) and repressed them totally by eating compulsively and ‘cutting off’ (just not being there). Over the last few years these unacceptable parts of myself have taken on an identity of their own. She is a separate person with a name, and I have no control over her behaviour when she acts out. I have successfully repressed her over the last few years by eating etc, but 3 months ago I was prescribed medication to stop my compulsive eating. Once the eating stopped, I could feel her coming back and one day she turned up to my therapy appointment, tried to seduce my therapist in a very aggressive manner and when he set a boundary and said no, she stormed out, found out where he lived and started posting hate mail through his door. He has, understandably, had to abruptly terminate our 5 year therapeutic relationship for the safety of us both and has referred me for psychiatric evaluation. He is continuing to support me over the phone and is adamant that the only way forward is for me and the other person inside me to integrate -something I think will destroy me (and she’s not too keen on the idea either). I am currently waiting for my appointment for psychiatric evaluation and trying to deal with all the grief and loss issues around the termination of my therapy, while my ‘evil twin’ rages about desperately trying to avoid all the abandonment stuff this has triggered in her by acting out all over the place (God I hate her neediness). What I want to know is whether you have ever encountered this situation in a BPD patient before (the splitting into two people, both of whom are aware of the other but have no control over the other) and what do you think will be the outcome of my assessment (which may take forever, knowing how slowly the British National Health Service works).
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Answer:
Yes I have come across this sort of split personality issue before in patients, although never before in the way you’ve described it (where there is an onset of the split in adulthood). No matter. The outcome of your assessment (insomuch as I’m capable of predicting – which is not much) is perhaps that you get a new diagnosis to complement your existing BPD. What you’re describing is known as dissociative identity disorder in the recent DSM (diagnostic and statistical manual), and what is thought to be occurring in cases like this is that, via a still poorly understood cognitive mechanism known as dissociation (whereby clusters of memories and feeling states become disconnected from one another) a person’s personality starts to exist as a set of fragments rather than as a whole person. Most always this sort of presentation tends to develop in childhood in response to significant abuse. Though the dissociated person acts as though there are multiple persons living inside herself and generally believes and perceives this to be the case, there are not really multiple people inside the one body. Instead, the whole person is all there, but the various parts of that person can’t or don’t want to recognize each other. No one is quite sure which of those possibilities are more true, but the net result is that the affected person tends to act in very erratic and often self-sabotaging ways.
When trying to treat DID, the goal of many therapists is ‘integration’ meaning that a cure will have been recognized to have occurred only when the various different personality fragments all get together and start looking through the same eyes. I’m no expert in this subject, but I have done this work in the past, and to my mind ‘integration’ seems like an impractical goal. A more practical goal is to get all the fragments on speaking terms, so that they can all ‘consult with one another’ as it were when decisions need to be made. To my mind the goal of a therapy for DID is to substantially reduce the erratic and self-sabotaging behavior, to increase the contact and interplay between the fragments, and most importantly to increase the responsibleness of the entire ‘system’ that makes up the person so afflicted. I’ve seen people accomplish this without achieving integration, and so I don’t think that true integration is a necessary goal. When you think about it, adding the DID component on top of the Borderline component doesn’t really change the goals of therapy too much. In terms of the work that needs to be done along the path towards ‘integration’ or semi-integration, or whatever you want to call it, the basic goals are to help the afflicted person to hold it together as best as possible, to teach coping and self-soothing strategies, and to help the patient to act less erratically and with more holistic self-responsibility. These goals are harder to accomplish with a true DID patient, but they are already plenty hard for a BPD patient to accomplish without the additional load. Of the therapies I’m familiar with, Dialectical Behavior Therapy is the best suited for meeting these goals, and substantial medication management by a qualified psychiatrist and supportive psychotherapy are also probably indicated. Your health service will hopefully do right by you.
