Holly Golightly, deduced by the wondrous Audrey Hepburn on the silver screen, devouring her breakfast in front of the glossy display windows of Tiffany's - I daresay that there has not been a more memorable scene in movie history. What struck me when I first watched the film was how tragic it was. Wandering on a lonely street in New York at the small hours of the morning, still dressed in a classy gown from the festivities of the previous night...The only thing that numbed the pain Holly endured was a visit to Tiffany's. Indeed, when meeting Paul Varjack for the first time, Holly conceded that nothing bad could happen to anyone at Tiffany's. As one avid in psychiatry, this has led me to think whether Holly Golightly, this legendary onscreen character, has a personality disorder. Her exotic lifestyle, turbulent emotional make-up, impulsive behaviour and undeniable liking for spirits - all these remind me of Borderline Personality Disorder (BPD).
BPD is first recorded in the Diagnostic and Statistical Manual of Mental Disorders (now in its fifth edition, published by American Psychiatric Association; also known as DSM-5), as one of the distinct categories of personality disorders. First, it is necessary to clarify what a 'personality disorder' actually is. In medicine, when we use the word 'disease' or 'illness', they refer to different things. Disease is a general term in description of something that doesn't work physiologically - or in the way they should. Illness refers to the personal experience, where one does not feel at health. [1] In psychiatry, we are wary not to label everyone insane. We are also cognisant of the dangers of subscribing a certain model of morality as 'normal', since embracing diversity is the key to a healthy, inclusive society. There is usually a time period associated with every condition labelled in DSM-5. For instance, for satisfying the diagnosis of general anxiety disorder (one of the variants of anxiety disorders), one's symptoms need to have lasted for most days in a 6-month period. [2] That time period is an indicator of the impact of an illness on one's quality of life. Quality of Life (or QoL) is the parameter clinicians use to assess how debilitating an illness/disease is. [3] A patient might experience problems in communicating with others, or lacks the ability to make decisions in daily life. These might warrant a contemptuous 'get a grip' from those who are less sympathetic, but to medical professionals, it is our duty to help these patients.
A personality disorder is when one's personality, with all due respect, is causing the person problems in daily functioning that warrants medical intervention. It is quite damaging to be branded 'personality disordered' - to patients, this label has grave effects. It is an authoritative stamp classifying the patient as an 'invalid', a person whose entire existence is a disorder. Thus, medical practitioners are very wary when giving this diagnosis, especially for younger individuals. The same goes for conduct disorder in adolescence, which carries a different type of stigma. As an introduction, under DSM-5 (the 'bible' of psychiatry; its counterpart is the International Classification of Diseases, ed. 11, otherwise known as ICD-11, published by the WHO), personality disorders are divided into three big categories: (1) odd/paranoid, (2) emotional and impulsive, and (3) anxious. Under each category, there are numerous types of disorders, some of which overlap. Patients assigned with one diagnosis is also likely to receive a second diagnosis due to the co-existence of features from two or more categories. BPD is under the second category- emotional and impulsive.
BPD is portrayed often in media, either overtly or covertly. Apart from Holly Golightly, another famous example is Kate Winslet in Eternal Sunshine of the Spotless Mind. As the name suggests, BPD patients are often thought to be living on the edge. The typical impression is one who drinks and gambles a lot. After losing much of his cash, he sits on a bench, his nails sinking deep in his flesh. He spends an exorbitant amount of time in brothels, using casual sex to fill the emptiness of his life. He doesn't get along with anyone well - with acquaintances and colleagues, he is irritable and bad-tempered, often bordering on aggression. With lovers and partners, they are temperamental. Sometimes exceedingly passionate, sometimes cruelly distant, their behaviour often makes romantic relationships short-lived. In life, there are moments when we feel depressed. We are bogged down by the little things which irritate us. We can also feel empty, since what we are doing is not working towards our final goal. However, for patients with BPD, this vicious constellation of behaviours has rendered them soulless. Their lives are severely affected by such propensities.
Holly Golightly first struck me as containing the superficial elegance of a call-girl. Prior to watching Breakfast at Tiffany's, I ardently supported the casting of Audrey Hepburn - this might be swayed by my personal preferences and sentiments. However, I am increasingly convinced that Marilyn Monroe, the actor favoured by Truman Capote himself (author of the book), should be the one to play Holly Golightly. The tragedy of her life was marked by her living off the charity of men. Her brother died in the army. To live, both physically and spiritually, she did not hesitate to have casual sexual relations with men and indulge herself in alcohol (at least from the scenes shown). External pursuits bordering on obsession might be an indication of internal emptiness. Her relationship with Paul Varjack was unique. They had ups and downs, with moments where Holly would rely on Paul for everything (including the time when Holly needed Paul to accompany her to the bus station to send Doc, her former husband, away), and also their fall-outs. Patients with BPD often have troubles forming stable, long-term relationships because of a creeping sense of instability. Travelling from extreme to extreme, it is unlikely they can easily find respite. Holly's quest for freedom, as exhibited by her reckless behaviour, such as the times when she fled Texas to find a new life, and left Los Angeles for New York just before casting, could also be an indication of her fear of external control. Everyone treasures freedom. Everyone desires liberty. This is how much personal autonomy means to us. But then, we don't normally flee from stressful situations just because we think there's a chance it might usurp us. Holly's behaviour might suggest a problem with the formation of her identity. As even she was not cognisant of who she really was, perhaps she was scared that others might take advantage of it and dominate over her core essence.
While Holly found her saviour towards the end of the film (spoilers - she ditched Brazil to be together with Paul; one of the most romantic scenes in Hollywood's history), in reality, patients with BPD are less lucky.* Modern treatment is confined to medication, primarily to reduce risk-taking behaviour, and cognitive behavioural therapy (more commonly known as talking therapy). Traditionally, we use mood stabilisers for symptomatic relief. These include topiramate and lamotrigine (both also being drugs for epilepsy - the reduction of cortical brain activity). [4] Nowadays, different clinical trials are underway. Anti-psychotics (drugs for psychosis, with symptoms such as hallucinations and delusions) are trialled and modest benefit is shown. Examples include quetiapine and olanzapine. Lower doses, such as 150 mg, are recommended. [5] In terms of talking therapy, several forms are recommended: dialectical behavioural therapy (DBT), mentalisation-based therapy, schema-focused therapy, transference-based therapy and STEPPS (emotional predictability and problem solving). [6] Without diving deep into the detail, these therapies target different aspects of BPD. For instance, DBT is used for understanding more intense feelings and ways to control them. Transference-based therapy develops a bond between the patient and therapist, where this bond forms the basis of constructing relationships with other people - a communication skill lacking in patients with BPD.
Some are saying that borderline personality disorder is problematic. Indeed, DSM-5 has its drawbacks. The orthodox model of categorisation does pose various problems, since we cannot slot a patient perfectly into one category. Many patients with BPD also have features consistent with other mental disorders, or other classes of personality disorders. Some even claim it is a myth, since there is no scientific basis of personality disorders. To persist in claiming they exist is to support the baseless theories of Sigmund Freud, a world-famous psychoanalyst before his propositions were widely attacked by the scientific community. However, requesting for a definite scientific basis for disorders is neither supportive, nor constructive. This is to further alienate patients with mental health problems and label their suffering as 'not important enough'. The problem of the current orthodoxy lies not in essence, but in form. While the approach is laudable, it is time we recognise that personality disorders should be graded according to severity, not in type. Recently, ICD-11 proposed a new model for understanding personality disorders. Utilising four domains of personality, a system by grade of severity is made. The focus is thus not on the characteristics that constitute to the illness (which can cause over-emphasis on a standard, normal form of morality), but the suffering of the patient - whether the patient has profound problems in communication and forming attachments with others. [7] The presence of an age-specifier also makes personality disorders an age-non-specific issue. It recognises the liability-threshold model, which means there is always a threshold to disease occurrence. Different factors push one's liability closer to the threshold. These can be either genetic or environmental. Thus, it follows that a person with a set of personality characteristics may flourish under a certain set of circumstances. Upon a rapid change of environment, one's personality becomes a hindrance and there are profound difficulties of adaptation. By shifting the focus back to the essence of psychiatry, we are answering to the true aim of medicine: healing.
Holly Golightly has always been my favourite onscreen character. The classy New York call-girl wandering outside Tiffany's, swishing in her little black dress. Her presence arouses the sympathy of the most heartless souls. In reality, patients with BPD may be less iconic, their suffering is not at all less significant. Their emptiness can only be compensated by the most addictive of habits. They externalise their lack of self-identity in the form of over-protection. We have to remove the stigma of mental illness and be more compassionate to those who might find it a little more difficult to be comfortable with others. One way of doing so is to drive the focus from the substance of personality traits to the impact the illness has on patients.
We are, after all, human.
*In this article, I prefer to say patients 'with' a certain condition. For instance, it is patients 'with' depression, not 'depressed' patients. This might be a subtle grammatical characteristic, but to me, psychiatry is all about the labelling. Adjectivising a disease may mean little to an outsider, but to a patient with mental illness, it means the illness actually defines them. They do not. The illness is what afflicts the patient, not a core characteristic.
[1] Boyd KM (2000). Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts. Medical Humanities 26:9-17.
[2] American Psychiatric Association. (2013). Anxiety Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm05
[3] I need to clarify that some individuals might experience an illness, but not a disease. This applies to psychosomatic disorders, where there is no detectable abnormality in physiology, i.e. all tests performed return with normal results. However, the suffering of these individuals is real. For more details, I recommend reading: O'Sullivan S. (2015). It's All in Your Head. London: Vintage.
[4] Olabi B, Hall J. (2010). Borderline personality disorder: current drug treatments and future prospects. Ther Adv Chronic Dis. Mar; 1(2): 59–66.
[5] Watts V. (2014). Antipsychotic Studied as Potential Therapy for BPD. Psychiatric News, 49 (16), 1-1. https://doi.org/10.1176/appi.pn.2014.8a11
[6] Choi-Kain L, Finch E, Masland S, Jenkins J, & Unruh B. (2017). What Works in the Treatment of Borderline Personality Disorder. Current Behavioral Neuroscience Reports, 4(1), 21-30. https://doi.org/10.1007/s40473-017-0103-z
[7] Bach B, First MB. (2018). Application of the ICD-11 classification of personality disorders. BMC Psychiatry18, 351. https://doi.org/10.1186/s12888-018-1908-3
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