What is the difference between BPD and the spectrum of dissociative
disorders?
In normal consciousness, we experience an exquisite and seamless integration
of a variety of neurological functions. We are perceiving input via all five
of our senses and integrating these perceptions into a meaningful picture of
reality. Current experience is also influenced by memory traces from the past
that are automatically called into awareness according to their relevance to
the present. New memory traces are constantly being created and stored. And
we must remember that we are not merely passive recorders of our environment
but interact with it via our various motor functions, altering both our
surroundings and our perceptions of them. Finally, to distinguish us from the
computer on which I record this message, we experience emotions, which
further color and individualize the content of consciousness.
Dissociation describes any conditions in which one or more of these
functions fail to integrate and are split off or dissociated from the
mainstream of experience. The dissociated piece may be a small fragment of a
function, for example a specific memory of a single event in time, or it may
be of more sweeping consequence, such as amnesia for the essential elements
of one's identity.
Dissociation may affect memory creation or retrieval, any aspect of sensory
input and interpretation, the capacity to execute motor functions such as
movement or speech, and the emotional coloring of experience. The cognitive
and emotional aspects of experience can be separated in more than one way.
The perception of one's surroundings may be robbed of all emotional tone as
in depersonalization. On the other hand, emotion can so dominate
consciousness that it blots out current reality as might occur in the
flashbacks that occur in Post-traumatic Stress Disorder.
Most of the dissociative disorders that have been defined are
well-circumscribed in scope and may, in turn, originate with a single intense
or traumatic emotional experience. There may be amnesia covering a specific
event or period of time. There may be a discrete alteration of sensory input,
such as tunnel vision or even an episode of psychogenic blindness (often
interpreted as an unconscious unwillingness to view something painful). Motor
functions may be affected as in the paralysis of a limb or an inability to
speak (which may be understood as unconscious recognition that something is
unspeakable). Such alterations of sensory or motor functions that are not
based upon physical diseases characterize the conversion disorders along with
pseudo seizures and other non-organic neurological dysfunctions. There may
even be apparent alterations of the individual's usual cognitive abilities.
Any of the dissociative symptoms may occur in BPD. Dissociative experiences
are a hallmark of BPD. They are generally more varied, more complex, and
often more persistent than the single symptoms that characterize many
dissociative disorders. All people with BPD dissociate. Only some people who
dissociate have BPD.
At the other end of the complexity spectrum is Dissociative Identity
Disorder. In Chapter 4 of Lost in the Mirror, I compared multiple
personalities to the channels of a radio or television. With this model, the
tuner would be governed by current circumstances and emotions, determining
which personality would be tuned in at any given time.
A more timely analogy would be Windows. As our computers become increasingly
sophisticated, I believe they approximate more and more closely how the brain
actually works. We are capable, like our computers of processing more than
one thing at a time. Our stored memories are like the hard disk. Our moment
to moment mental processes resemble what a computer is processing in RAM.
Consciousness is like the top window, with other functions running in the
background. As I type this paragraph, my computer is using another part of
its RAM to try to log onto AOL. While I select my words I am also aware of my
aching muscles from an earlier workout and of rising tension as the hour
advances and time begins to run out on this task. With all that and more
going on in the periphery of consciousness, my brain is also regulating my
heart rate, blood pressure, rate of respiration and other bodily functions.
In Dissociative Identity Disorder, the personalities are taking turns
occupying consciousness, but they are all simultaneously present and
processing experience. And while only one window is on top, sometimes
fragments of the other windows can be seen around the edges. For example, hear
ing voices could be understood as an intrusion of information from one window
(or personality) into the space of another. Many forces determine which
personality commandeers consciousness for the moment. If I drift from my task
of writing, my screen saver will suddenly obscure this text. And even if I am
intently persistent in my task, AOL will preempt the screen if it ever
actually connects. Similarly, an alternate personality might take over when
the attention of the personality occupying consciousness begins to drift or
when an alter develops an urgent agenda that demands conscious attention.
Discontinuity of experience is perhaps the single most defining feature of
BPD. DID is an extreme version of this fragmentation. I believe that every
person with DID also meets criteria for BPD. Only a fraction of people with
BPD, however, experience the degree of fragmentation that occurs in DID. The
spectrum of dissociative disorders therefore begins at one end with single
dissociative events, moves toward BPD in which the tendency to fragment
experience is fundamental, and finally to DID, which may be understood as an
extreme form of BPD in which the dissociative experiences are complex and
systematized.
© Dr. Richard Moskovitz
What does the borderline diagnosis mean to me as a doctor?
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By A.J. Mahari © 2005-2007
