Emotional
Hyperbole,
Patient
MARY
F
R
A N
C
The authors
nism,
C.
ZANARINI,
F. S
R.
hypochondriasis,
that
to be central
of this
derline
personality
are seen
tion
measure
have
stages
use of this
quelae
and
an active
been
and
three
of treatment
defense
1994;
and
tions.
expectable,
that
treatment
if overlap-
the
stemmingfrom
its behavioral
of Psychotherapy
sePractice
3:25-36)
that
young
it may
is unable
images
have
been
the
and
ering
object
have led
constancy.
child’s
mothering
his mother.
been inborn
by real
view
of these
that failures
theories,
in early
to a failure
Because
that
fear
Received
February
accepted
September
Belmont,
Massachusetts,
8,
1993.
and
ment
of Psychiatry,
Harvard
Massachusetts.
Address
reprint
McLean
JOURNAL
OF PSYCHOTHERAPY
revised
AND RESEARCH
often-
the child
of himself
or
of stress
to
pronouns
theories,
Masterson3
is the
cen-
5, 1993;
September
From
McLean
the Consolidated
Hospital,
Depart-
Medical
requests
Boston,
Zanarini,
Hospital,
115 Mill Street,
Copyright
© 1994 American
PRACTICE
Adler
moth-
and
of abandonment
2, 1993;
a
of himself
to develop
stable
the pre-borderline
and nonempathic,
a consistent
view
used inclusively.]
In the third of these
suggests
child
ambivalent
others
that he can use in times
comfort
and sustain
himself.
[Note: In this article
masculine
are
frustra-
and negative
to achieve
was inconsistent
times insensitive
fails to develop
has
and
pre-borderline
to merge
his positive
and
attendant
affects
others.
In the second
Buie2 suggest
and
and
have
caused
case,
realistic
and
treatment
disorder.
Kernberg’
excessive
early aggression
child
to split his positive
In either
more
theories
the devel-
phenomenology,
and
of borderline
personality
in the first of these theories
negative
images
of himself
This excess
aggression
may
or
emo-
major
psychodynamic
been proposed
to explain
suggests
led the
adapta-
events
Twelve
opment,
course
Briefly,
attempt
in large
childhood
validated.
pa-
subjective
has been shaped
that
are detailed.
(The Journal
Research
Borderline
of tremendous
of
and
of bor-
if tenuous,
by traumatic
never
implications
ping,
as making
a tolerable,
pain
stance
defined
phenomenology
disorder.
in the face
tional
also
hree
have
is hy-
manifesta-
hyperbolic
patient-is
to the complex
to maintain
behavioral
defense-the
related
T
to borderline
The
the borderline
tients
M.D.
FRANKENBURG,
mecha-
psychopathology.
tion
ED.D.
define a new defense
emotional
pot hesized
Hypochondriasis,
and the Borderline
School,
to Dr.
Belmont,
Psychiatric
MA 02178.
Press,
Inc.
26
EMOTIONAL
E
HYPOCHONDRIASIS
tral factor in borderline
psychopathology.
He
believes
that the mother
of the future
borderline patient
interfered
with her child’s
natural autonomous
strivings
by withdrawing
We believe
emotionally
dependent
the primary
defense
of borderline
G. E. Vaillant6
originally
defined
when
manner
development
that
ration-individuation.”
require
independent
crudescence
ment
panic
the
child
during
acted
the
in an
phase
Mahler4
has termed
experiences
behavior
lead
“sepathat
to a re-
driasis
abandonpatient
felt
pulses,
plaints
Later
of the dysphoria
that the borderline
as a child
when
insoluble
dilemma
behave
dependently
faced
and
with
(either
or lose
inof
a seemingly
continue
to
needed
emo-
tional
support).
Each
of these
theories
has helped
clinicians
to better
understand
and treat borderline patients.
However,
each
theory
has also
unnecessarily
pathologized
patient
by focusing
on what
be structural
ciencies.
In
borderline
basic
Adler
the borderline
are perceived
to
defects
and/or
functional
defithis regard,
Kernberg’
sees the
patient
as having
too
much
of a
human
drive
or instinct-aggression.
and Buie,2
although
deeply
empathic
to the
patient,
subjective
see him
of the borderline
too little of a basic
suffering
as having
ego function
needed
for adult
functioninglibidinal
object
constancy.
Masterson,3
though
also holding
a warmly
empathic
of the borderline
patient’s
emotional
sees his primary
fear as being
left alone,
that
recent
to the
initially
research
borderline
formulated,
relatively
subtle
being
of primary
In contrast,
psychopathology
has shown
failures
to maintain
of relationships
internal-who
sponse
behaviors
tionally
liberately
nor
such
to
in
as
and
mothering
as
a difficult
adaptation
left gracefully.
We
pathology
develops
serious,
on the part
incompetent,
malevolent,
in
with people-both
can neither
be loved
chronic
that
N A L
emotional
as “The
toward
loneliness,
hypochondriasis
is
patients.
hypochon-
transformation
others,
or
of reproach
arising
from
unacceptable
bereavement,
aggressive
into first self-reproach
of pain,
somatic
and then
illness,
imcomand
neurasthenia.”
He also believed
that
“The
mechanism
may permit
the individual
to belabor
others
with his own pain or discomfort
in lieu of making
direct
demands
upon
them
or in lieu of complaining
ignored
his needs
(often
dependent”
(p. 384).
driasis
underlies
the
that others
unexpressed)
and
plague
The
helplessness
and
this
tion engenders
documented
Building
in physicians
in the clinical
on Vaillant’s6
lieve
that
rage
emotional
have
to be
In this view, hypochonsubjectively
real but ob-
jectively
untreatable
disease
with which
hypochondriacs
mates
and family
physicians.
that
discomfort
their intifeelings
of
type
of situa-
have been
well
literature.79
definition,
we be-
hypochondriasis
is best
defined
as the transformation
of unbearable
feelings
of rage,
sorrow,
shame,
and/or
terror into unremitting
attempts
to get others
to
pay attention
to the enormity
of the emotional
pain
usually
etiological
significance.
we believe
that
borderline
can best be seen as an active
the
real
comfortably
lieve
that
specific
patient.5
Each
theory,
also focuses
on early
attempt
face
and
is not
alview
plight,
a fear
0 T I 0
M
HYPO:IIONDRIASIS
that
indirect
of the listener’s
“malevolence.”
one
feels.
and
involve
These
attempts
a covert
“insensitivity,”
are
reproach
“stupidity,”
or
We
presence
believe
that paying
attention
to the
of this defense
has three
important
functions
identify
or consequences.
borderline
patients
ond,
it provides
namics.
Third,
for
also bein re-
their
a different
it provides
First, it helps
to
accurately.
Secview of their
clear implications
dy-
treatment.
Identification
of Borderline
Patients
maladaptive
of immature
and
but not necessarily
caregivers.
VOLUME
emode-
S
#{149}
NUMBER
The
“wastebasket”
tient
who
1
WINTER
#{149}
borderline
term
was not
1994
diagnosis
was originally
a
used
to identify
any
obviously
psychotic
paor
ZANARINI
clearly
AND
27
FRANKENBURC
neurotic
in character
structure
and
and
nothing
that
can
be
stated
once
goes
level of functioning.’#{176} Research
has outlined
four areas of psychopathology
that are most
characteristic
of borderline
patients:
1) intense,
dysphoric
affects;
2) cognitive
distortions,
especially
dissociative
experiences
and
unrepeated.
In other
words,
much
as Willie
Loman’s
wife in The Death
of a Salesman23
believed
that “attention
must be paid”
to his
deteriorating
situation,
borderline
patients
insist that attention
be paid to the enormity
transient
of their subjective
emotional
pain-pain
that
is often consciously
perceived
and openly
discussed
as “the worst pain anyone
has felt since
stress-related
paranoid
ences;
3) impulsivity,
acts and manipulative
intense
and unstable
by such
problems
entitlement,
ever, research
types of Axis
as devaluation,
a sense
abuse,
unipolar
eating
ders.’2’
specific
the
depressions,
disorders,
and
However,
none
to or pathognomonic
personality
of
and
demandingness.”
Howhas also shown
that many other
II patients
exhibit
one or more
of these
kinds
of symptomatology.5
more,
research
has shown
that
patients
manifest
a variety
of Axis
especially
experi-
especially
self-mutilative
suicide
efforts;
and 4)
relationships,
marked
the
1.The
substance
anyone
disoris
display
2.
at
the
is particularly
personality
borderline
important
disorder;
diagnosis
describe
angry,
difficult
patients5
is both
impulsive,
and
patients
who present
ble Axis I disorders
cians
may
mistake
with
we believe
underused
3.
her
the
old
soon take on a transThe patient
who commother’s
gross
will soon
therapist’s
patient
non-
complain
gross
about
insensitivity.
who
Like-
complains
psychopharmacologist
about
who
could
not cure her dysphoria
somnia
will soon complain
new psychopharmacologist’s
and inabout
her
lack of
ability
to do the same.
This transferential stance
of being
completely
miseraKeys
Emotional
outward
line
is the
patient.
that
can
fense
of various
do not yield to reaor angry
confrontatend to increase
in
when
inappropriately
and
empathically
confronted.24
her
intractathat cliniof these
presence
or undergo
a transformation
something
equally
maladaptive
wise,
to describe
with seemingly
or symptoms
for
one
comabout
others
intensity
insensitivity
interpersonally
Particularly
the
that
disorders.22
The
and/or
borto
of unre-
I symptoms.
Real-life
conflicts
ferential
quality.
plains
about
her
overused
a series
the
or one major
but
lament.
These
comcan be about
almost
These
complaints
son, reassurance,
tion. In fact, they
into
toms
and/or
Axis I disorders;
recognizing
emotional
hypochondriasis
allows
the clinithis plethora
of clinical
data
way. This ability
to diagnose
presents
complaints
shifting
or laments
or anything.
Axis
able to recognize
hypochondriasis
began.”
keys to recognizing
hypochondriasis.
mon, however,
are complaints
the lack of understanding
that
work allows
the clinician
to accurately
identify the borderline
patient.
Such
a patient
may present
with a bewildering
array of symp-
derline
patient
mitting
perhaps
plaints
anxiety
world
are three
of emotional
Furtherborderline
I disorders,
of these
disorders
for borderline
We believe
that being
defense
of emotional
accurately
of the
There
presence
disorder.’2’
cian to organize
in a meaningful
history
to Identifying
Hypochondriasis
manifestation
ble and passively
team of treaters
of
this
de-
hyperbolic
stance
of the borderTo put it most succinctly,
nothing
be stated
dramatically
JOURNAL
is said
simply
OF PSYCHOTHERAPY
will soon engender
that will eventually
expecting
to remove
rescue
fantasies
be replaced
with
countertransferential
peration,
tion.227
PRACTICE
helplessness,
These
feelings
AND RESEARCH
a treater
or
this misery
feelings
and
are
of exasexhausa
28
particularly
ence of the
chondriasis.
helpful
defense
guide
to the
of emotional
and
preshypo-
Again,
the
that
defense
of emotional
represents
attention
an
must
be
paid.
cry
tients
empty
Hyperbolic
speech
and behavior
are characteristic
borderline
patient
when
this defense
ative.
(“No one knows
how much
I am
ing and the misery
I feel. I’m in agony
one knows
or cares.”)
The
etiology
defense
remains
unclear.
Psychodynamic
relatively
subtle
glect.28’3#{176}’32
on the childhood
patients
pointed
experiences23’
forms
of
borderline
patient
pletely
has
furious
is not
problem
suggested,
that
he
suffering
ne-
has
from
aggression,
is simply
been
someone
else’s
anger,
depression,
lessness
that was unjustly
taken
Thus,
unlike
Adler
and Buie,2
that the borderline
patient
has
left
lieve
that
borderline
themselves
patients
because
a
to bear
trouble
have
also differs
from that
believes
that borderline
of being
abandoned
VOLUME
S
NUMBER!
#{149}
afraid
of staying
in an
are terrified
of being
house-a
of what
house
have
others
is understandable.
somebody
in
important
No
else’s
dirty
one
the
have
a meaningful
way
that
pain
research
pain of being
can go a long
endless
efforts
supports
this
off
is
havin
is justified.
can ever take away the
by a car, but an apology
warding
anger
of never
acknowledge
your
to
Equally
their
frustration
hurt you
and
pa-
wants
clothing.
understanding
understanding
ing those
who
have
at legal
view
of
borderline
dynamics.
Studies
have
consistently
found
that
borderline
patients
are
more
likely
than
those
with other
forms
of
such troubling
images,
affects,
and memories
inside-images,
affects,
and memories
that
are more
accurate
than
not reflections
of
their
pathogenic
childhood
experiences.
This conceptualization
of Masterson,3
who
patients
are terrified
tients
wear
toward
reparations.
Recent
as
com-
they
so much
as they
in a haunted
by the memories
way
or helpout on him.
who believe
failed
to de-
have
are not
house
Nothing
run over
velop
libidinal
object
constancy
as a result
of
relatively
subtle
failures
in parenting,
we becomforting
of aloneness
to them
and what
they, in turn,
to themselves
and others.
Given
this background
of betrayal
gross
insensitivity,
the rage of borderline
expeto the
and
emotional
with
but
profound
done
done
We believe
that the crucible
for the development
of this defense
is the situation
where
the child
has been
repeatedly
and
deeply
hurt
or brutalized
by one
or both
parents,
but the validity
of this experience
has
never
been
acknowledged.
In this view, the
constitutional
Kernberg’
feelings
trapped
haunted
of the
is opersufferand no
of this
the-
ories
have
tended
to focus
on the role
of
maternal
failures
during
the separation-individuation
phase
of ego development.’3
The
first wave of research
riences
of borderline
role of early separation
with
being
left with other
peoples’
pain that inconveniently
inhabits
their
bodies.
To put this
another
way, we believe
that borderline
pa-
hypo-
unremitting
HYPOCHONDRIASIS
and emptiness.
In contrast,
we believe
that
borderline
patients
are not so much
afraid
of
being
left alone
as completely
fed up with
Dynamics
chondriasis
left
EMOTIONAL
personality
tive
disorders
disorders
or
to have
sexual
abuse.20’3739
ters of borderline
childhood
told, about
a history
abuse.57ss
derline
with
often
nonpsychotic
a history
In addition,
patients
report
history
of severe
80% of borderline
affec-
of physical
or
three-quar-
a chronic
verbal
abuse.M
All
patients
report
of one or more
forms
of childhood
Studies
have also found
that borpatients
a serious
unipolar
or character
are
likely
psychiatric
depression,
pathology.40’4’
ries of studies
has
borderline
patients
shown
are
to have
a parent
disorder-most
substance
abuse,
In addition,
that the parents
often
reported
a seof
to
have been neglectful
of both their emotional
and physical
needs?42
Thus,
recent
research
supports
our clinical impression
that borderline
patients
are
often
mistreated
WINTER
#{149}
1994
by their
caregivers-and
in
ZANARINI
AND
29
FRANKENBLRG
gross
and
dramatic
rather
than
subtle
ways.20’3739
Recent
research
is also consistent
with our belief that this mistreatment
was not
plications
directed
ciated
with the
on this defense:
inchoate
inner
development
of and reliance
the presence
of intense
but
pain and an almost
absolute
insistence
others
solely
by personal
malevolence
to-
ward
the child
but rather
arose
from
general
immaturity
and psychopathology
the
parents.404’
Additionally,
studies
concerning
are consistent
with
the
serious
forms
our belief
that
the
of
results
of
of neglect
borderline
results
They
1.
of existing
do not di-
rectly
assess
the issues
of secrecy
and
in the families
of borderline
patients.
blind us to the
of constitutional
children
similar
can
and
environmental
3.
seeming
mood
of dissociation
been
language
or
pawhen
OF PSYCHOTHERAPY
and/or
shame,
found
when
interested
to listen.
articulate
common
the
and
In this
patient
inner
Try
to help
the
in a meaningful
Conceptualizing
emotional
hypochondriasis
as the core defense
of borderline
personality
disorder
leads
to 12 treatment
implications.
Although
none
of these
treatment
im-
useful
in
ele-
terror,
rage,
and sorrow
clinician
willing
is
and
regard,
a particudescribed
her
state as “exasper-
ated dysphona,”
which
she went on to
describe
as an agonizing
admixture
of
rage, anxiety,
and sorrow
that she felt
as an alien entity
throughout
her entire
body.
gone
on to
by serious
IMPLICATIONS
the
he is
We
emo-
is particularly
of anxiety
frustration,
often
able
larly
most
to
4.
JOURNAL
in terms
symptoms
Try to help identify
the constituent
ments
of the patient’s
pain. Chronic
genuinely
psychopathology.
TREATMENT
situation
than
Validate
the enormity
of the pain
patient
feels. Acknowledging
that
in tremendous
pain reflects
the
are
and have not
psychopathology.
other
types of serious
such
as antisocial
per-
others
have
lives unmarred
acknowlawkwardly
clusters.
Most borderline
will feel better
understood
feelings
intense
of borderline
also does not
exposed
rather
both
asso-
this validation
process
(e.g., “Growing
up for you was like living in an emotional
concentration
camp.”).
failures
developed
borderline
Some
have developed
character
pathology,
sonality
disorder;47
lead
productive
have
patient’s
pain
tional
possible
etiologic
significance
factors.4
Clearly,
some
be
the
of felt
they
with
are
patient’s
subjective
experience.
have found
that using
powerfully
can be linked
to their reliance
on the defense
of acting
out.6 Similarly,
the hypervigilance
of
borderline
patients
can be linked
to the de-
belief
that the pain
has been
hard earned
together
told, “You are in terrible
pain”
than
when
told, “You have an affective
disorder.”
Our belief
in the centrality
of emotional
hypochondriasis
does not blind
us to the importance
of other
defensive
operations.
Plainly,
the impulsivity
of borderline
patients
Our
patients
taken
empathically
Frame
tients
2.
and their
and failure
that
symptom
denial
Caveats
fense of projection,
swings
to the use
and denial.6
is entirely’new,
ways for a therapist
to deal
key elements
that we believe
edge
this pain
regardless
of how
and indirectly
it is expressed.
patients
are expected
to bear
their
pain
in
silence
and/or
deny
its existence.ss42
However, more
research
is particularly
needed
in
this last area because
the
studies
are only suggestive.
suggest
of the
patient
historical
place
his pain
context.
Al-
though
borderline
patients
want their
pain acknowledged,
they often
cannot
immediately
identify
the reasons
for
this
pain.
dissociation,
abusive
PRACTICE
This
inability
may be due to
shame,
or habituation
to
experiences
that would
seem
AND RESEARCH
30
EMOtiONAL
to the objective
observer.
Try to help the patient
see his life as a
unified
narrative
with a beginning,
a
us only partially
self-defeating.
catastrophic
5.
middle,
and
an end.
unfolds
and
that
over the
will help
Knowing
one
direction
to alleviate
has
that
some
and pace
panicky
one has
not give
in trying
life
control
often
quite
tenuous.
Try to show the patient
for help are so indirect
that
and
that only a fellow
traveler
to recognize
them.
This
ultimately
that some-
have it, or engage
in some
combination
of both.
Acthat those who have hurt
and denigrated
them
gave them
what
they could
is difficult
for borderline
patients
but necessary
for their recovery.
Few people
will try to break
into a store
his pleas
disguised
that is obviously
is useful
for the
will be sure
will be diffi-
learn
cult, for borderline
patients
are sure
they are accurately
communicating
the
depth
of their suffering
and that most
other
people
are knaves,
abusers,
or
both.
In this regard,
we have found
that
the
a tearful
empty.
Additionally,
borderline
patient
world
person
bering
the many
times that your parents told you that you were ugly and
stupid
and then went out and received
actually
his “dis-ease,”
will only
regressive
spiral
or the premature
nation
of treatment.
In contrast,
praise
patient,
for
their
friends
charitable
ing and say you are
on your antidepressant
more
understanding
in the
desperate
Don’t
efforts.
at three
attempts
calm,
ally available
morn-
going
to overdose
if they aren’t
in the future.
This
only makes
people
feel angry
and helpless.” Although
this may seem self-evident,
often
it will be a revelation
to the
9.
use
conversational
if he believes
tone
will
suffice.
Try to help
who have
ple rather
the patient
see that those
hurt him so are limited
peothan simply
deliberately
with-
and
and
stead
forms
of criticizing
of misbehavior
tempts
to control
no more
makes
ing
person
for
than
tient
survival
strategies.
tend to believe
selfish
and/or
framing
tect the
approach
patient’s
VOLUMES
to
NUMBER
#{149}
emotion
of true
suffering
maneuvers
his resultant
holding
or sadistic.
Both clinical
experience
and recent
research
findings49 suggest
that borderline
patients
that their parents
are
evil. This belief
seems
face
of interpersonal
of worthlessness
a normal
genuinely
is
to a
termibeing
(such
as manipulation,
demandingness,
devaluation)
as helpful
attempts
teach you about
his chaotic
early
ences
that
and
what
lead
will begin
to teach
the borderline
patient
that the unbearable
can be borne
and
the unspeakable
can be spoken.
Try to frame
the borderline
patient’s
going
to shout
yourself
from
him, such as
to medicate
in the
borderline
patient,
who has been
taught
the language
of desperation
and
hyperbole
as a child.
Clearly,
no one is
to bother
to
clenched
fist.
Try to demonstrate
to the patient
that
you can be most helpful
by bearing
with him while he learns
to bear his
8.
pain. Efforts
to distance
his pain or even silence
your
it
to
responds
better
one with a
than
that practicing
helps.
For example,
one
might
say, “Try to tell people
that you
are very angry
because
you are remem-
call
7.
correct
and
If you believe
something
good and just will
it to you, you may well persist
to get it, endlessly
lament
that
you do not
exhausting
knowledging
of change
feelings
that the pain will never
end or will end
too soon.
It will also help to instill
hope
in these
patients,
in whom
hope
is
6.
HYPOCLIONDRIASIS
1
WINTER
#{149}
intense
inner
and
to
experifeelings
badness,
these
maneuvers
or sadistic
at-
your behavior.
sense
to chide
his poor
table
inas
It
a starvmanners
it does to chastise
a borderline
pafor holding
on to these outmoded
1994
the rewill serve both to proalready
low self-esteem
Additionally,
ZANARINI
AND
and
ity
demonstrate
10.
your
to collaborate,
unusual
faith
albeit
way,
Never
31
FRANKENBURG
in the
attack
the
derline
in his abil-
in a somewhat
therapeutic
pain
work.
borderline
a defense
inconsistently
loved person.
did not have
ships,
cial
Rather,
not
continually
not
keep
would
he
person
but
the
If the borderline
some hope
about
he would
out.
by the pahypochondriaof the
loved
who
is without
flee
from
unpatient
relation-
seeking
join
the
the
pain
times
that
have
11.
he has
them
hurt
others
forgive
expressing
their anger
the destructive
power
they frequently
where
angry
contrast,
in learning
and
Numerous
and/or
the
sorrow
struggle
trouble
line
that
in turn,
feelings
panic.
PnAsls
authors
have
patient
is roughly
but
often
During
which
In
first
his
in
or frightening
way
behaving
no one
is
leaves
foxhole
until given reassurance
the shelling
is really over.
Be prepared
for the borderline
to resist
ment
getting
process
well
and
a
that
complaints
for
the
treatThe
OF
three
bor-
PSYCHOTHERAPY
treatment,
voice
PRACTICE
indirect
about
of
phase,
but
(seemingly
the
lack
efforts,
Regardless
presentation,
task of the therapist
the patient’s
words
express
his deep
patient’s
seeming
tempt
for
gests
that
someone
patient
to be prolonged.
JOURNAL
of
of
reframing
ways
cide gestures).
initial
style
alternative
the
therapist
to
like any reasonto give up this
a clear
phase
pain
The
able
until
into
phases.
of emotional
hypochondriasis
operative,
and the patient
attempt
to communicate
incompetence
and/or
erate
seif-mutilative
thinking,
feeling,
and
firmly
in place.
Plainly,
divided
termed
as it has and
and move on.
struggle
their
the defense
will be fully
repeatedly
less
life
the
we have
dening
that
one’s
patient,
is reluctant
presented
overlapping
could
only have unfolded
now it is time to mourn
borderline
person,
or
gives rise to
of desperation,
Refraining
had any help
sorrow.
Fur-
acknowledges
is over,
early
belittled
directly
from families
was the norm.
never
their
patient’s
his pain
views concerning
the phases
that constitute
the effective
psychotherapy
of the borderline
patient.3’5’54
In our experience,
which
was
informed
by the work
of these
previous
authors,
the successful
therapy
of the border-
and they fear
of their rage,
come
conflict
they have
to bear
thermore,
12.
experi-
of the
of having
TLIERAPEIJTI:
are slim if his
those
who
have
and
descence
separate
often
it has
that the
is being
recru-
rage,
him.
they
First,
of his identity
thus cherished.
Third,
any hint
therapist
believes
that progress
made
brings
about
an affective
Try to remember
that the affect
borderline patients
dread
most is sorrow.
Although
up his
and
of hon-
inadvertently
hurt
cannot
giving
reasons.
core
denied,
which,
overwhelming
est intimacy
through
seemingly
mindless acting
out.50 There
is another
reason
to avoid such attacks:
the patient will be quick
to perceive
that his
chances
of being
forgiven
for the many
deliberately
therapist
three
the
ences
antiso-
hope
resists
thus represents
what is known
and to
some degree
safe. Second,
it represents
lost loves that have gone
awry and is
parents
or other
loved ones. No matter
what they have done
or failed
to do,
sis is typically
for
formed
patient’s
they are loved and needed
tient. In our experience,
patient
end-
the
the
AND
RESEARCH
delibsui-
patient’s
primary
is to repeatedly
reframe
and actions
as efforts
to
inner
pain.
Despite
the
indifference
to or con-
these
efforts,
our experience
he is inwardly
appreciative
is trying
to understand
and
to his inchoate
mad-
therapist’s
of caring,
repeated
of
will
his
concerns.
sugthat
give
32
EMOTIONAL
The
end
of
this
phase
of
treatment,
the
which
is similar
to Masterson’s
testing
phase,3
is usually
marked
by three
important
changes.
crease
First,
there
will be a noticeable
in the frequency
and intensity
patient’s
indirect
hyperbolic
means
of
behaviors
communication
deof the
(reliance
such
on
as
self-destructive
behaviors
and complaints
others’
insensitivity).
Second,
the patient
begin
to admit
will usually
that
he is in pain,
be unable
although
to articulate
if he
began
he
the reasons
for this pain or to detail
its elements.
the patient
will usually
have returned
or school
of
will
treatment
Third,
to work
as an
inpa-
tient or will have begun
to stabilize
his occupational
or academic
functioning
if he began
treatment
as an outpatient.
This
will both
enhance
his self-esteem
and provide
a range
of opportunities
for real-life
tions that will make further
progress
These
changes
will be neither
him with
reparapossible.
initiated
nor
patient’s
maintained,
however,
unless
the
patient’s
emotional
flip
sides
of one
another,
able
him
expectations
in expectable
of
being
needs
reabused.
to
help
tween
appropriate
assertiveness
and
those
have
been
“forgotten”
not believe
that
and that his therapist
he is now “all better.”
does
which
During
the
is similar
second
phase
to Masterson’s
through
phase,3
plore
the nature
the
and
patient
etiology
and
the
of treatment,
working-
will begin
to exof his pain. The
reasonableness
of
therapist
differentiate
be-
of anger
and
cruel
toward
concerning
fact that
they
the former
ple, “Being
the general
“rules”
apply
to everyone
situation,
asked
is not
abused
of life and
is helpful.
the
In
one might
say, for examto get up by nine
in the
the
same
the
as being
same,
but
while
being
was for theirs.”
In the
say, for example,
have suffered,
tortured
as
getting
hurt
up
and
latter
situation,
“No matter
how
it doesn’t
give you
it out on someone
only makes
you
else.
feel
This
even
worse
about
yourself
and may lead to your
getting
rejected
again.”
We believe
that this
approach
is helpful
because
it allows the therapist to empathically
join with the patient
in
therapist
has two primary
tasks during
this
phase.
The first is to help the patient
examine
the often
chaotic
childhood
experiences
that
have led to the development
of his pain; the
second
is to validate
the reality
of these experiences
the
patient
expressions
actually
being
the right to take
kind
of behavior
Validation
im-
therapist
needs
between
the
placing
reason-
with whom
he is close. In both cases, we
found
that
an educational
approach
morning
not
particularly
Second,
the
one might
much
you
has
to his chaat the same
nature
of
events.
actually
the
on him or disappointing
ways, and the experience
minded
his pain
are
portant
to address.
First, the
to help the patient
differentiate
experience
of others
either
a child.
It may feel
is for your
benefit,
that
response
otic childhood
experiences
while
time pointing
out the self-defeating
his behavioral
responses
to these
Two self-defeating
patterns,
therapist
engages
in an iterative
process
whereby
the patient
is encouraged
in his efforts to make
progress
but is continually
reby his therapist
HYPOCHONDRIASIS
the
trying
to deal
of everyday
holds
the
that
with
life,
patient
he intuitively
Additionally,
that
the
pain
the
inevitable
while
at
accountable
knows
are
it is important
engendered
pattern
of emotional
well be as excruciating
frustrations
the
same
time
for behaviors
it
self-defeating.
to remember
by an
abuse
and
as the
alternating
neglect
may
pain
engen-
patient’s
emotional
response
to them.
This
latter
task will be difficult
because
borderline
dered
by physical
and sexual
abuse;
thus, this
kind of pain needs
and deserves
to be treated
patients,
like
other
trauma
often
alternate
between
intense
of reliving
agonizing
past events
with
that they ever occurred.
difficult
because
the
This
therapist
survivors,55’56
experiences
and denying
task will also be
must validate
VOLUME
S
#{149}
NUMBER
as
much
traumatic
search
has
ures
usually
which
I
these
WINTER
#{149}
respect
experiences.
shown
that
as
In
these
serve
as the
more
dramatic
1994
the
more
fact,
more
background
failures
clearly
recent
subtle
refail-
against
occur.57
ZANARINI
AND
The
end
33
FRANKENBURG
of
which
we have
will be marked
The first change
this
phase
of
others
treatment,
therapist
to direct
his anger
at those
who have truly
disappointed
and hurt
him
rather
than
at
those who are trying
to help him. This in turn
will allow him to begin
to work
through
his
feelings
of worthlessness
as he realizes
that he
is carrying
the
rage
and
hopelessness
of oth-
ers with him through
a combination
uation
and identification.
As one
dysphoric
patient
put
it,
thought
I was a really
no reason.
Now I see
“All
this
time
I’ve
for
my
hurt
him and how
others.
The primary
is to bear
with
the
were
wasted
in an empty,
type of reparation
coming.
A secondary
therapist
is to help
many
subtle
but
tient.5’
Throughout
tient
well
described
by
authors
Winnicott58
and
The second
Alice Miller.59
change
is that
gradually
many
cease
personal
strategies
poorly
as an adult
being
devaluative).
constitutes
true
though
haviors
reasons
them;
the
first
he
of the
as
varied
as
the patient
will
desperate
that have served
him so
(e.g., clinging,
demanding,
In our experience,
this
character
change
even
patient
is likely to stop these
and only afterward
to discuss
bethe
why he so vigorously
maintained
is unlikely
to stop them
as a result
of discussing
them.
This
change
seems
partly
therapy
facilitated
by the support
and partly by the reparations
by life
(such
as finding
a concerned
being
admired
by a close
friend,
cherished
by a romantic
partner).
is easier
to be direct
with people
needs
when
one feels well loved
one has managed
to inadvertently
alienate
inter-
everyone
one
to be
offered
by
offered
has
these
been
about
one’s
than when
anger
and
knows.
Mourning
During
which
we
the patient
the third
have termed
will focus
phase
of treatment,
the mourning
phase,
on his sorrow
at how
JOURNAL
OF PSYCHOTHERAPY
this
he
that
foster
ous
the
pa-
suffering
and ends
over the heartache
in disparate
places,
factors
and
the
a continuum
are
responsible
of and
inner
pain;
2) true
real world
that help
that
by
the
pa-
stages,
1) validation
self-esteem
of a
detailed
along
three
his
belief
pursuit
concerning
borderline
three
moving
process:
articulating
ments
in
to disprove
autonomous
the
help
in
achieveboth
to
errone-
behavior
is sure
to be punished
by abandonment;
and 3) a
genuinely
sustaining
relationship
that allows
the patient
to get sufficient
distance
on his
feelings
of inner
badness
and distrust
of others so that he can begin
to bear the pain of
facing
his past and letting
it go. Both
hope
and gratitude
are essential
if the chronic
suffering
of the borderline
patient
is to be transformed
into
for
unfortunate,
the
genuine
respect
even
and
true
horrific,
sorrow
events
of
his life.
Clearly,
mentor,
or being
Plainly,
it
while
changes
we believe
for
angry
essential
get rid of it, I would
process
of reclaiming
This
been
patient
Adler in their article
treatment
of the
that starts
with inchoate
with genuine
mourning
of his life. As noted
above
better.”
self has
has hurt
task of the
that will never
be forthbut crucial
task for the
the patient
achieve
the
father’s
rage around.
He abused
me, and I’ve
spent
most of my life being
a psychiatric
patient. This rage is his, not mine.
If I only could
feel so much
the true
he
mourns
for the lost years of his life. Plainly,
it
is difficult
to admit
that years
of one’s
life
Buie and
definitive
of habitchronically
angry
person
and
that I’m carrying
have
and
himself
termed
the validation
phase,
by two important
changes.
is that the patient
will begin
our
mon
with
the
cated
by Adler
its emphasis
the patient,
has
approaches
and
Buie2
and
much
in comadvo-
Masterson.3
In
on the subjective
experiences
our approach
also owes much
the self
relations
psychology
theory
childhood
tionally,
our
by
work
the
approach
empathic
of
of Kohut,6#{176}’6’the object
Winnicott,58’62
and
the
observations
formulation
of
of
to
those
of Bowlby.63
Addihas been
enhanced
concerned
with
the
characterological
However,
our
effects
of trauma.5556’59’
approach
owes the most to the
adaptational
approach
PRACTICE
AND RESEARCH
advocated
by
G.
E.
34
EMOTIONAl.
Vaillant,6’
which
implies
that
therapy
can
measure.
be
most
than
other
effective
by facilitating
change
rather
by actually
effecting
it. To put this anway, borderline
patients
will mature
in
their
own
them
accountable
be helped
time
if we
proach
(as
patient
and
many
frustrated
them
to admit
containing
patients
they
ap-
subjects.
naturalistic
therapists
the
do)
error
and
We
paying
DIRECTIONS
apy
FOR
and
hypochondriasis
pirically.
Luckily,
Currently,
niques
for
andJ.
dinal
lant
specificity
immature
can
personality
attention
of borderline
et al.,67
these
of this
de-
the high
dropout
of the psychother-
patients.67’
and
the
measure
third
of
dysphoria,
have
recently
to append
U
U
S
N S
1 0
has been
has led
ance
on
hypochondriasis
Axis
I
self-deany of
a series
self-report
that
This
work
of
was
has
and
ignored
or belitboth
to the reli-
of
emotional
development
of the
of the
borderline
rather
than
patient.
viewing
such
anxious
dread,
one can admire
with which
they have dealt with
their pain. After all, not many people
so loyal to and so respectful
of such
ening
and demeaning
experiences.
presented
remain
disheart-
at the Second
Interna-
tional Congress for the Study of Personality
Disorders, Oslo, Norway,July
30-August
2, 1991, and
the Sixth
developed
to Bond’s
defense
and the
stance
suggest
patients
with
the integrity
videotaped
physically
studied
using
the
hyperbolic
We
is the longituof G. E. Vail-
intractable
deliberately
acts)
can be
C
the resulting
pain
tled. This situation
of
of Bond
is the
N
out-
are three
main
techdefense
mechanisms.
self-report
0
the borderline
patient
in his childhood,
paradigms.
We
questions
whether
presence
In our experience,
suffered
enormously
clinical
vignette
method
of Perry
and Cooper.#{176}The
hyperbolic
behaviors
associated
with
borderline
personality
(unremitting
symptoms,
structive
disorder,
to the
emout
as markers
S. Vaillant,
the second
clinical
vignette
method
complaints
borderline
II control
emotional
defenses,
be studied
there
studying
is the
of
have yet to be assessed
as Vaillant6
has pointed
to other
ward behaviors
this new defense.
first
defined
Axis
are also planning
to assess,
in a
study of the longitudinal
course
C
in regard
we
RESEARCH
presence
The
instrument,
the specificity
of this
behaviors
in a sample
both carefully
near-neighbor
of borderline
of their
modified
fense
mechanism
reduces
rate found
in most studies
FUTURE
The
this
are currently
assessing
series
of hyperbolic
hold
for their behavior,
but
by taking
a superego
will not
and forcing
ways.
are
Using
HYPOCIIONDRIASIS
International
line Patient,
1991.
Symposium
Tokyo,
Japan,
on the Border-
November
20-21,
REFFRENCE
1. Kernberg
0: Borderline
Narcissism. New York,Jason
Conditions
5. Zanarini
in Pathological
Aronson,
MC,
GundersonJG,
Discriminating
1975
2. Adler G, Buie D: Aloneness
and borderline
psychopathology:
the possible
relevance
of child
developmental
issues.
IntJ
Psychoanal
1979; 60:83-96
other
Axis
II disorders.
147: 161-167
6. Vaillant
GE: Adaptation
3. Masterson
J: Treatment
cent:
A Developmental
Brown,
7. Lipsitt
1972
4. Mahler
process
phenomena
nal Study
M: A study
of
and
its possible
of
the
Approach.
the
Borderline
New
Adoles-
York,
Wiley,
situation.
VOLUME
Psychoa-
S
1977
DR: Medical
and
personality
J
Psychiatry
Life.
Boston,
Am
to
NUMBER
#{149}
9. Nadelson
character
T: The
features.
psychological
1. WINTER
1994
Munchausen
Gen Hosp
FR, et al:
disorder
of “crocks.”
IntJ Psychiatr
Med 1970;
8. GrovesJE:
Taking
care of the hateful
J Med 1978; 298:883-887
separation-individuation
application
to borderline
in the psychoanalytic
Child
1971; 26:403-424
Frankenburg
borderline
from
1990;
Little,
characteristics
1:15-25
patient.
spectrum:
Psychiatry
N EngI
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