Introduction
Borderline personality disorder [BPD] grabs hold of the lives of millions of people. There are many symptoms, risk factors, treatment methods, and even its prognosis that make it distinguishable from other mental disorders. Girl, Interrupted brings that to life by following the story of Susanna Kaysen who agrees to receive treatment for BPD. BPD is not always noticeable at first, but by the time the audience begins to get a glimpse into her life, Susanna is visibly exhausted, irritable, and anxious. While Susanna is not the most expressive regarding her symptoms, what she struggles with is quite real ‘ apparently, even in the 1960s.
Symptoms & Diagnosis
After reluctantly agreeing to admit herself to Claymoore Mental Institution during a short therapy session, Susanna is diagnosed with BPD. Unfortunately, following her dramatic story, this appears to be a more-than-accurate diagnosis. BPD is characterized by maladaptive patterns consisting of intense mood shifts, unstable self-image, and extreme efforts to avoid real or imagined abandonment; other common symptoms involve self-harm, dissociation, and suicidal ideation or threats (National Institute of Mental Health [NIMH], 2017). Despite Susanna’s seemingly reserved behavior, these problems are quite apparent. Unfortunately, Susanna and many people like her may be unaware of the problem. Her admission to Claymoore seemed to be prompted by the retired therapist informing her that her behaviors were harming others around her. On top of the symptoms listed above, she seems to also be quite reckless, however that may be in an effort to stabilize her self-image ‘ a problem that is consistent with people who have BPD.
The most prominent example supporting Susanna’s diagnosis is the scene in which she is horribly dissociative, being rushed through a hospital on a gurney. She believes the bones in her wrist to have disappeared following a suicide attempt in which she had taken a bottle of aspirin with vodka. Suicidal thoughts, threats, and attempts are especially common among people with BPD, as approximately 60 to 70 percent of people with the disorder attempt suicide; with around 10 percent achieving completion (Kearney & Trull, 2015). In defense of herself, Susanna tells Dr. Wick that she ‘wanted the shit to stop.’ This hints toward feelings such as guilt and her struggle with unstable moods. The suicide attempt may have been a result of her promiscuous behavior with a married man.
Sexual promiscuity is another feature of BPD, falling under a category encompassing reckless behaviors. Unsafe sex is rightfully associated with BPD because people with BPD tend to pursue casual sexual interactions, a higher number of partners, and tend to have sex earlier in age (Sansone & Sansone, 2011). Patterns of not only sexual promiscuity, but other reckless behaviors are evident in people with BPD possibly due to low self-worth and their unstable self-image. Susanna had an affair once and defends her casual interactions, stating that all sex is casual. Other reckless behaviors include her escape with Lisa and hitchhiking.
In order to better understand Susanna’s diagnosis, the time in which she received it must be considered. Her diagnosis was received in 1960s, in which BPD was considered to be a ‘waste-basket diagnosis;’ even with Roy Grinker and his colleague’s research in 1968 distinguishing BPD as its own ‘syndrome’ (Friedel, Cox, & Friedel, 2018). It would have likely been by chance that Susanna received a diagnosis that reflected her struggle. BPD was not even an official diagnosis until 1980 when it appeared in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition [DSM-III] (Lieberman, 2004). She simply could have been described as ‘borderline’ due to not only the lack of knowledge among psychology professionals, but her inability to meet the criteria of another disorder current to that era.
Nature or Nurture
As mentioned by Melvin, Susanna’s therapist, genetics play a role in the development of BPD. There are both genetic and environmental risk factors associated with BPD. Someone who has a parent with BPD or has experienced childhood neglect or maltreatment is more likely to develop BPD than someone without one or both of those risk factors (Kearney & Trull, 2015). During the therapy session including her parents, Susanna is critical of her mother’s dramatic behavior. When Melvin states that genetics play a role, Susanna’s mother, Annette becomes frustrated and abruptly excuses herself from the room.
Even with little context, Annette is portrayed as being somewhat domineering, needing to control the situation and unable to handle when things do not go her way. Her discussion during Susanna’s therapy session portrays those features well. While it may not have been well-understood before, it seems a genetic risk factor is almost necessary for the development of BPD (Friedel, Cox, & Friedel, 2004). Environmental risk factors could potentially trigger the disorder. As mentioned above some potential risk factors could include physical, sexual, and emotional abuse. It is possible that an over-controlling, emotionally detached parent could inadvertently encourage BPD symptoms. Those are features hinted in Annette’s behavior.
Treatment
Treatment in the 1960s was likely less-than-ideal. During Valerie’s confrontation of Susanna’s behavior’s, Valerie asserts that Claymoore is a ‘five-star hotel’ in comparison to state facilities. Overall, mental health treatment primarily consisted of harsh psychiatric drugs with a bit of talk therapy. One man recalls a similar experience, in which the better facilities he was admitted to offered treatment with medication and no plan for handling his symptoms upon release, while others were filthy and overcrowded (Carney, 2005). With little to do, people in an institution could have easily found themselves bored. When people are bored, they may stir up more trouble. Perhaps this was better than the lobotomies performed prior to the 1960s, but mistreatment and neglect is just that.
Currently, there are laws preventing the mistreatment of people with mental disorders, emphasizing their dignity and care. This has allowed more ethical treatment methods and the expansion of such methods. One method commonly used in the treatment of BPD is Dialectical Behavioral Therapy [DBT]. DBT teaches people with BPD mindfulness skills, which can train them to be more aware of their situation and control their response (NIMH, 2017). Since many people find themselves lost in the moment underneath all of the intense emotions, this is an optimal treatment method.
DBT can also be paired with psychiatric medications including antidepressants, mood stabilizers, and antipsychotics. These types of treatment can help to quickly stabilize mood swings to ease the burden of navigating therapy. Antipsychotics are typically the first line of defense for treatment of BPD because of they can reduce psychotic, paranoid, or ‘split’ thinking (Freidel, Cox, & Freidel, 2018). Second-generation, or ‘atypical’ antipsychotics are newer and pose less harsh side effects than their older neuroleptic counterparts. Mood stabilizers such as Topamax or Lamictal also show efficacy in treatment of BPD. Either drug class is seen as the most effective, however if treatment fails, a psychiatrist may suggest antidepressant medications.
Prognosis
BPD used to be seen as untreatable. Some of that stigma still remains, even among medical professionals. However, there is a positive prognosis for people who have BPD. Improvement is seen over time despite the possibility of relapse and high comorbidity rates (Biskin, 2015). For BPD, it seems that time is the key for many people. However, treatment will only work if the person continues with it. Susanna showed us during her escape that people with BPD often quit treatment prematurely. It is typical for treatment to be ‘on or off’ over the years, which likely poses the greatest risk for poor outcome in patients. People with BPD are likely to return, however, such as Susanna did. ‘Bad influences’ could also cause poor progression such as Susanna’s friendship with Lisa. With determination and a willingness to change, it is likely that one can gain control over BPD.
Conclusion
Even using today’s criteria, Susanna’s diagnosis turned out to be accurate. Her struggle with BPD was portrayed in a way that is also relatable. The symptoms, genetic and environmental factors, treatment process of that time, and prognosis are all addressed. The movie also may have also brought to light the tendencies of a ‘quiet borderline;’ or someone with BPD who internalizes their feelings. It also showed a BPD case on the opposite end of the spectrum through Lisa’s outwardly aggressive and reckless behavior. The reality of misdiagnosis is also apparent via Lisa’s sociopathy diagnosis. What is astounding about the film is how people are able to view the differences in how a mental disorder may affect someone; and while it may have been more on the dramatic side, Girl, Interrupted is quite realistic.