One of the criteria for diagnosing borderline personality disorder (BPD) is identity disturbance. Identity disturbances include such things as feelings of emptiness or unintegrated and contradictory self-images (Gunderson 2001; Goldstein 1995). Interestingly, though, the clinical literature offers little in the way of understanding identity disturbance, or even what the constructs of ‘identity’ and ‘identity disturbance’ are. As Tess Wilkinson-Ryan and Drew Westen say, the literature variously refers to BPD identity confusion as ‘fragmentation, boundary confusion, and lack of cohesion… These concepts are difficult to operationalize, however, and several questions remain, such as the extent to which identity disturbance is a unitary phenomenon …’ (Wilkinson-Ryan and Westen 2000, p. 528). Theodore Millon describes identity crises as ‘nebulous symptom clusters’ (Millon 1996, p. 205). Furthermore, little research is directed at understanding identity disturbance in BPD patients. One notable exception is the work of Zanarini et al. (1998), who examined dysphoric states reported by patients diagnosed with BPD. One cluster of characteristics came under the construct of ‘identitylessness,’ which included ‘feeling like I am evil, like a small child, unreal, like people and things aren't real, like people can see right through me, like I have no identity, like I'm someone else, like other people are living inside me’ (Zanarini et al. 1998, p. 205). These researchers report that, along with other states, identitylessness, understood as an ‘absence of a core feeling of continuity about oneself,’ contributes to ‘despair and desperation among borderline patients that may not be appreciated by even the most knowledgeable of clinicians’ (p. 205). However, Sharon Miller suggests that BPD women view themselves as estranged from others and inadequate according to social standards but not as having an impaired sense of self or an identity disturbance (Miller 1994).
This chapter raises questions about the construct of identity that is prevalent in Western psychiatry – that is, a construct that neglects the impact of an increasingly obsessive interest in acquisitiveness and consumerism in producing feelings of emptiness; that neglects the subordinate status of females in medicalizing identity confusion; and that assumes that where boundaries between ‘inner’ and ‘outer’ are drawn is universal across cultures. The effects of materialism, and gender and cultural differences, press against the prevailing view of identity disturbance. There are elements in each of these factors that challenge the prevailing view – factors that have an impact on interpreting women who fit the diagnosis of BPD – and this chapter develops these themes below. We diagnose through symptoms, so it is crucial that we examine both those cultural pressures and influences and the way we come to see certain behaviors as symptoms. This chapter, then, takes issue with the values that underlie the metaphysics of self-identity as it pertains to mental health. Yet experiences of identity problems can be troublesome and distressing for the patient. Such experiences can disrupt her interpersonal relationships and exacerbate a sense of alienation from others, prompting other behaviors such as impulsivity or self-injury in order temporarily to fill the void. Clinicians cannot ignore patients’ expressions of identity issues regardless of the messiness and assumptions of the concept.
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