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Rising to the Challenges of Borderline Personality Disorder

W.W. Norton & Company, 1992

Its relationship to the topic of an earlier book inspired Dr. Cauwels to write about borderline personality disorder. A main selection of the Behavioral Sciences Book Club, Imbroglio has been endorsed enthusiastically by most of the leading experts on the illness. Unlike most hardcover midlist books, which are remaindered within months, Imbroglio was in print for 11 years. One reader recently contacted Dr. Cauwels to request ongoing guidance 27 years after being interviewed for it.

Jacket Endorsements

"Dr. Janice M. Cauwels has written a comprehensive, lively account of our evolving understanding of the borderline personality disorder, in fact, of the entire field of personality disorders. Imbroglio should help the educated public to understand and sympathize with the suffering of borderline patients and those close to them and the enormous difficulties and challenges confronting the clinicians treating them."
Otto F. Kernberg, M.D.
Associate Chairman, Department of Psychiatry, and Medical Director, New York Hospital-Westchester Division
Professor of Psychiatry, Cornell University Medical College

"Dr. Janice M. Cauwels has written a gem of a book on borderline patients. It is clearly written, concise, well-researched, thorough, empathic, and a pleasure to read. Imbroglio will become the standard for a work in psychology that can be read by the general reader, mental health professionals, and patients, all of whom it will enrich."
Gerald Adler, M.D.
Director, Medical School Education, Department of Psychiatry, Harvard Medical School

"Dr. Cauwels eschews the simplistic and the dogmatic to give us a work which accurately reflects the complexity of borderline personality disorder. Not a simple book, but a rich tapestry of first-person descriptions, clinical vignettes, facts, and opinions, written in a style which makes complexity enjoyable and enlightening."
Rex William Cowdry, M.D.

"In this breathtakingly comprehensive book, Dr. Cauwels has achieved a humanization of her complex and elusive subject not elsewhere seen in the literature and has returned the borderline patient to a position meriting therapeutic empathy."
Thomas G. Gutheil, M.D.
Associate Professor of Psychiatry, Harvard Medical School

"I recommend Imbroglio enthusiastically to all who seek to broaden their understanding of the fundamental nature of borderline states and their effective treatment."
Michael Strober, Ph.D.
Professor of Psychiatry, UCLA School of Medicine

"[A work of] absolute genius . . . Imbroglio is the vade mecum on borderline personality disorder."
John H. Greist, M.D.
Professor of Psychiatry, University of Wisconsin-Madison Medical School

"Imbroglio exceeded my high expectations. Beyond exploring borderline personality disorder as a diagnosis, the book brings to life real human beings who struggle in ordinary but illuminating language to reveal their inner pain, personal torment, and pervasive sense of aloneness."
Eric M. Plakun, M.D.
Austen Riggs Center, Stockbridge, Massachusetts

Professional Journal Review Excerpts

" . . . enthusiastically recommended for students of psychiatry, residents, nurses, and other mental health workers who deal with borderline patients. . . . Imbroglio is an extensively researched, well-written, and eminently readable overview of borderline personality disorder. However, more important than the information transmitted, the reader gains insight, empathy, and compassion for a group of patients who unfortunately are often described in pejorative terms."
Mary Helen Davis
Hospital and Community Psychiatry
(a journal of the American Psychiatric Association now published as Psychiatric Services)

" . . . both readable and informative. . . . [The author's] grasp of the relevant biological, psychological, and social and political factors is excellent. What is particularly striking and appealing about this book is that it is aimed at clinicians, researchers, and patients alike. To write about a controversial subject like `borderline personality disorder' for such a wide audience is no small task. To succeed furthermore in remaining sympathetic to the problems of both patients and clinicians is quite an achievement."
Mark Berelowitz
British Journal of Medical Psychology

"It must be rare to describe what is in essence a textbook on this difficult subject as a rattling good read. . . . A particular strength of the book is its clear, simple and even-handed approach to most of the major controversies in the field. . . . This is an informative, wise and compassionate book [that] deserves to be widely read."
Cath Allen
Clinical Psychology Forum

"The author has taken a formidable subject and been able to reduce it to manageable dimensions, producing a book I have always wanted. [She condenses] a wealth of research and information into brief but meaningful explanations."
Harold Graff
Readings: A Journal of Review and Commentary in Mental Health

"The book is interesting for its use of material from interviews with patients and therapists. . . . Overall, this is a readable overview which puts some human flesh on the bare bones of the DSM-III-R criteria and is likely to help raise general awareness of the problems of people with personality difficulties."
Graham Ash
British Journal of Psychiatry

Excerpt from Chapter 21, "The Social Smorgasbord"

A social factor is one that borderlines actually do perceive and react to, not what theorists think they react to just because it's in the air. The average person might suppose, for instance, that by dramatically confusing and ill-defining their roles, the feminist movement exacerbated identity problems in women that made them prone to borderline personality disorder (BPD). Or perhaps it prompted women to renounce natural interdependency for autonomy, thereby making relationships more difficult to maintain.

But suppose that the incidence of BPD were thought to have decreased during this time. The average person might then think that along with increased paternal involvement in child rearing, today's greater independence, more acceptable emotional expression, and enhanced self-esteem for women have benefited the entire family.§

     §Data actually suggest that the feminist movement has reduced psychiatric
      illness in women. "The problem is that borderlines may be an especially
      sensitive group that doesn't follow general trends," says Dr. Paris. "Since the
      1960s, the frequency of suicide attempts among women has increased."

Placing it in a social context makes the already diffuse borderline concept fizzle toward meaninglessness. Theorists see everything about today's society contributing to BPD. Society offers so enormous a smorgasbord of possibilities that one can pick and choose influences to support or refute any thesis. This is why history is subject to reinterpretation and why if borderline symptoms were described to almost anyone, that person could explain them culturally.

A New Epidemic?

Commemorating the 100th anniversary of the National Geographic Society a few years ago, Russell Baker's column in the New York Times identified, with brilliant precision, the reason that today's children don't know geography. Our increasingly permissive society, Baker explained, allows modern children to satisfy their natural curiosity about the human body simply by consulting television or other readily available media that feature nudity. Unlike previous generations of giggling voyeurs, today's children need not search for naked people in back issues of National Geographic (4).

Baker's thesis is a delightfully plausible selection from the social smorgasbord that readers of a certain age can cheerfully confirm. The same cannot be said for many reasoned theories about how social patterns affect this or that, which are sometimes equally questionable and always considerably less fun.

Millon believes that we have what he calls "a contemporary epidemic of BPD," one that he attributes largely to "two broad sociocultural trends that have come to characterize much of Western life this past quarter century" (5). One is the emergence of social customs that exacerbate faulty parent-child relationships, the other the diminished influence of other factors that in earlier times would have compensated for this problem.

Nobody knows for sure, however, whether this epidemic is new or whether therapists are finding more BPD because they are looking harder with better diagnostic criteria. References to an epidemic remind me of the "discovery" of bulimia nervosa in the late 1970s, when I was interviewing women who had hidden their binge-vomiting for up to 30 years.§

     §In Fasting Girls (Harvard, 1988) Joan Jacobs Brumberg likewise shows that
      anorexia nervosa, another disorder considered a purely contemporary phenomenon,
      was prefigured by the habits of medieval ascetics and first emerged as a
      modern illness in the Victorian era.

That BPD wasn't as apparent several years ago doesn't necessarily mean that it wasn't widespread. Perhaps much acting out took place behind the same closed doors that hid the prevalence of childhood sexual abuse.

More important for our present purpose, a thesis such as Millon's blurs the distinction between prevalence and etiology. Millon's explanation implies that like other pathological aspects of modern life, the two trends he identifies are both unprecedented and among the most relevant social influences on BPD.

This premise ignores the crucial factor already mentioned by Dr. Gunderson: it is not events that contribute to the development of BPD, but how the susceptible person experiences them. (In a psychiatric conference lecture, I have suggested likewise that each patient's experience of a mental disorder itself, rather than just the symptoms, is what is essential to understand fully [6].)

The same holds true for social factors. We assert confidently, for example, that no horror in history compares to the prospect of nuclear holocaust. Would that we could return to the Middle Ages and debate that point with a survivor of the Black Death! To suggest that modern society is uniquely stressful is grossly to underestimate the very sophistication that produced it.

A predisposition to BPD could be exacerbated by any fast-paced, unstructured society lacking alternative sources of solace and nurturance to compensate for deficiencies in family life. But ours is not the only such society to have existed over the past few centuries. To use an example that might surprise readers, let us go to Victorian England and see what other social factors unique to that society might have helped two women to develop BPD.


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