A risk of misdiagnosis of Borderline Personality Disorder?

Althea Hayton

Introduction

A “Vanishing Twin” pregnancy only lasts a short time and one of the twins dies. This can be witnessed on ultrasound. Extensive studies of vanishing twin pregnancies have been made since the 1980s. (Landy, H. J. and L. G. Keith 1998) There are many signs that there was at some stage one or more additional embryos or fetuses present during the pregnancy. The natural wastage of embryos at the start of pregnancy is considerable (Landy, H. J., S. Weiner, et al. 1986) A detailed study of many thousands of pregnancies (Boklage, C. E. 1990) revealed that for every live-born twin pair there are 10 twin pregnancies that end with a sole survivor. As approximately 1% of births are twins, that figure suggests that at least 10% of the population is made up of womb twin survivors.

Physical effects

The advent of ultrasound in the 1960s, and its widespread application in pregnancy by the 1980s, led to a new awareness of the frequency of this syndrome. A new question arose: was there any deleterious effect on the survivor if they lost their twin before birth? At first, there seemed to be no discernible physical ill-effects (Landy, H. J., L. Keith, et al. 1982; Landy, H. J., S. Weiner, et al.1986: Saidi, M. H.1988; Huter, O., C. Brezinka, et al. 1990; Landy, H. J. and L. G. Keith 1998) but by the turn of the 21st century some researchers were becoming concerned. In 2001 a female child who had both male and female chromosomes was diagnosed as being the result of a vanishing twin pregnancy. (Lloveras, E., J. M. Lecumberri, et al. 2001) In 2002 it was suggested that there might be neuro-developmental consequences for the survivor, particular cerebral palsy (Pharoah, P. O. 2002) or severe learning disability. (Pharoah, P. O. 2007). This idea remains current (Anand, D., M. J. Platt, et al. 2007, Harvey K. 2007)

Psychological effects

Because most twins are lost in the first trimester, the possibility of a psychological effect on the survivor of such an early loss has been dismissed as unlikely. The cerebral cortex of the unborn child’s brain, let alone the fetal brain, has been widely considered to be insufficiently developed, although various paradigms of non-verbal memory are considered possible by some. (Neisser, U. 2004) However, it is now recognised that babies are conscious at birth (Chamberlain, D. B. 1998) and with the help of hypnosis, memories of birth can be accessed and expressed with surprising clarity. (Chamberlain, D.B. 1980/1999). More and more discoveries are being made about cellular memory, neural networks created while in the womb. (Wade, J. 1996) Birth and pre-birth trauma is constantly relived by the individual concerned, particularly in the case of lone surviving twins (Woodward, J. 1998).

Womb Twin

In the light of these new developments, a study was started in 2002 in the UK based on a website, www.wombtwin.com, which provided an online questionnaire for website visitors to complete. The questions were compiled from some of the most characteristic feelings, attitudes and behaviours which had been mentioned in communications from womb twin survivors from all over the world via the website. Over a period of five years, five versions of the questionnaire were created, as more and more characteristic responses were uncovered and later validated by other womb twin survivors by means of later versions of the questionnaire. In 2007 a full analysis was made of 225 in the fifth version, using only the results from 112 respondents who had clear proof of the previous existence of their twin. Only the very strongest responses were counted. This enabled a tentative psychological profile of womb twin survivors to be created. From this research we have created a new hypothesis: womb twin survivors seem to spend their lives re-enacting the life and death of their lost twin. Nothing appears to be more important than that, even life itself. (Hayton, A. 2008)

The psychological effect: a congruence with BPD

Unexpectedly, after analysis of the questionnaire and an extensive literature search, it became clear that womb twin survivors share most of the symptoms of what has been called “borderline” personality disorder (BPD.) Persons with BPD were once considered by psychoanalysts to be “on the borderline between neurosis and schizophrenia”- hence the name. (Langley M.L.1994) BPD is a vague term: it has been observed that many personality disorders can be seen operating together in one individual, such as bi-polar disorder, substance abuse or eating disorders (Zanarini M.C. et al.1998) so it is possible that these symptoms signal something else. To demonstrate this congruence more clearly, I have set out below in a series of tables the results of the 2007 questionnaire survey with womb twin survivors described above, related to a list of headings taken directly from the list of BPD symptoms according to the DSM. (American Psychiatric Association 1994). I have included short quotes from womb twin survivors in their own words, to further illustrate the points made.

Frantic efforts to avoid real or imagined abandonment

The Wombtwin.com research has shown that nothing causes more pain to a womb twin survivor than to feel abandoned or rejected. If we allow for some kind of pre-birth impression of twin loss, it can be surmised that abandonment or rejection is just a bit too close to that original experience of being left alone in the womb and losing forever the closest relationship that Nature can provide. Rather than be left to manage life alone, the survivor will remain in a relationship long after it is over. Some womb twin survivors pre-empt rejection by avoiding all attempts at intimacy. Some of the questionnaire statements reflect this tendency:

Abandonment

I fear rejection 72.9%

I feel different from other people 67.4%

Deep down I feel alone, even among friends 62.2%

I fear abandonment 64.2%

I find disappointment very painful 48.4%

I am afraid being alone in the dark 33.6%

I don't let other people get close to me 32%

The womb twin survivor can feel alone, even among friends, and may find being physically alone very hard indeed, yet paradoxically they deliberately keep themselves apart from others, feeling alienated and different. They may avoid intimate relationships and may even re-enact the loss of their twin by sabotaging good relationships, so they are left friendless and alone. To the survivor this is an uncomfortable but psychologically important form of self-isolation.

Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

It is fast becoming clear that for womb twin survivors the primary attachment was to the twin, but the twin died before birth. This creates an interesting complexity to attachments in born life, as the survivor seeks a substitute twin in all intimate relationships thereafter, and yet each time sabotages the relationship in an unconscious re-enactment of the original loss. This unstable style of making and breaking interpersonal relationships is reflected in the following statements.

Unstable relationships

I always feel in some way unsatisfied but I don’t know why 56%

All my life I have felt restless and unsettled 55%

I am easily bored 48.7%

I get very intense and involved at the start of a relationship but then I sabotage it somehow 47.8%

I easily get into a love/hate relationship with individuals I want to get close to 40%

Many adult survivors report feeling restless, always changing their jobs, moving round the world and never staying anywhere very long. The search continues for Someone to make things right again and fill the empty space inside. Sometimes some short-term respite is found, such as in a satisfying job or a loving relationship, but very soon it is time to move on. This is the search for the lost twin - who was lost and can never be found.

Identity disturbance: markedly and persistent unstable self-image or sense of self

In a re-enactment of the short life of the lost twin, who didn't develop adequately but was too weak to survive, the womb twin survivor takes on the characteristics of the twin who didn't make it and remains in some way undeveloped and unfulfilled. Some womb twin survivors do not learn from their mistakes and do not get the best out of their situation in life but remain a shrivelled fragment of the person they could be. It was in fact their womb twin who ended up as the shrivelled fragment of what they may have become. Some of the statements on the womb twin questionnaire strongly reflect this fragile sense of self:

Unstable sense of self

I know I am not realising my true potential 69.7%

I suffer from low self esteem 51.8%

Deep down, I feel very vulnerable, as if it would not take much to totally annihilate me as an individual 50.2%

All my life I have been pretending to be someone else, and I know it’s not my authentic self 39.2%

I have been in an exploitative relationship with another person 34%

I have a strange irrational feeling that I don’t exist, that “I’m not really here”. 36.4%

A tendency to identify with the lost twin obscures a sense of the real self as the surviving twin. Womb twin survivors may appear to be enjoying a normal life, but inwardly they may remain in a child-like state, depending on others in their fragile “weaker twin” self, which can lead to being exploited or even abused, while their “strong survivor” self yearns for supremacy. The hypochondriac womb twin survivor, despite being perfectly healthy in fact, lives like a helpless infant, feeling weak and terrified of illness and death:- It was their twin who was too sickly and weak to survive.

Chronic feelings of emptiness

Womb twin survivors commonly report a vague feeling of “something missing.” The sense of something missing requires a pre-existing sense of “something there” which is now gone. As a way to heal this uneasy sense of emptiness there is a strong tendency in womb twin survivors to hold onto possessions, long-dead relationships, meaningless rituals, habits and entrenched, irrational ideas. There is a very strong resistance to making life changes or letting go of anything of sentimental value, as is clear from some of the questionnaire statements: (Table 5.)

Emptiness

I have been searching for something all my life but I don’t know what it is 68.4%

There is one room in my home, including a shed or garage, that is completely full of stuff 45.3%

All my life I have felt empty inside 48.4%

I find it hard to let go of unfinished projects 48.9%

This inner emptiness is experienced by the womb twin survivor as a void or a “black hole”, into which one can pour all manner of activities and energy but it remains an experience of emptiness. It appears to be a constant re-enactment of the brief life and eventual death and loss of the lost womb twin.

Impulsivity in at least two areas that are potentially self-damaging

The search for some way to fill the sense of lack - the space left by the missing twin - may take the survivor into an eating disorder or an addiction. Compulsive hoarding is particularly common. These activities appear to be an attempt to heal the emptiness and primal wounded-ness, but in fact they tend to perpetuate the pain and distress, which usefully keeps alive the memory of the twin. Some questionnaire statements reveal a distinct lack of self care:

Damage to self

I am addicted to substances or behaviours that are potentially damaging to my health, wealth or well-being 27.9%

I have a long term problem with food and eating 45.7%

I feel driven by "musts" and "shoulds" 41%

I want to succeed but I always end up somehow sabotaging my chances of success 44.7%

A frenetic, exhausting and self-sabotaging lifestyle is characteristic of many womb twin survivors. They tend towards “burn out” and, after an extended period of over-activity, will fall into a state of utter exhaustion and be unable to function at all for some time. It is as if they cannot allow themselves to be strong and healthy and long-lived. They seem to be testing their ability to survive to the very limit and do not seem to care if they mutilate themselves or even die in the process. To some womb twin survivors there is a kind of rough justice in a risk-taking lifestyle.

Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

Characteristically, the womb twin survivor thinks a lot about death, to the extent of preoccupation. Ideas of suicide emerge early in life, frequently in childhood. Some womb twin survivors describe having no desire to be born, as if they “don’t want to be here in this life.” This preoccupation with death is clearly demonstrated in the following statements from the questionnaire:

Preoccupation with death

I have wanted to commit suicide more than once in my life 40%

I think a lot about death and dying 38.5%

Somehow I know that I experienced death before I was born 36.6%

I feel very privileged, simply to be alive 31%

I have suffered for a long time from feeling vaguely unwell, as if I am slowly dying 30.1%

I compulsively self harm 11.2%

As the haunting memory of death intrudes into the everyday life of the womb twin survivor, it can be interpreted as a bodily weakness, unrelated to any medical condition, which feels very real and debilitating and can even be disabling. Conversely, the very idea of being alive is to some womb twin survivors a surprise gift - perhaps undeserved - and a great privilege.

Affective instability due to a marked reactivity of mood, such as intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.

Womb twin survivors appear to be prey to intense emotions that seem to have no rational explanation. They suffer frequent changes of mood as they seek out explanations for the vague feelings of painful distress that haunt them all their lives. This affective instability is reflected in the following statements;

Reactivity of mood

All my life I have carried deeply felt emotional pain that persists, despite all my efforts to heal myself 54.8%

I grieve deeply and for a very long time when someone close to me (or a beloved pet) has died 49.6%

It upsets me if I am unable to reduce the suffering of others 42%

I am so intuitive and empathetic that it is a problem for me 48.1%

I often find it difficult to fall asleep, even when I am very tired 45.3%

I suffer from depression 48.7%

I sometimes feel unable to cope with life 36.8%

I get extremely upset about silly little things 29.8%

Womb twin survivors are in a constant search for rational reasons for the feelings they have, and may need to create fantasies of ill-treatment in order to do this. They are often unusually sensitive to the feelings of others, and this, coupled with their own inner sense of weakness and fragility, can render them frequently unable to cope. They can become so taken up with the feelings and affairs of other people that they can’t get to sleep at night. They feel a great need to heal others of their pain. They usually work in the caring professions and often become therapists, but never for very long, as they tend to become overwhelmed by their clients’ distress.

Inappropriate, intense anger or difficulty controlling anger

The womb twin survivor is often angry but its not always clear to anyone exactly why. It is a defensive kind of anger, as if they are protecting themselves from a potentially hostile world. Their defensiveness draws hostility from others, who are unlikely to be able to understand the paradoxical sense of inner fragility that the anger is designed to defend. The result is often a shouting match, which the womb twin survivor cannot afford to lose, for in the womb the weak go to the wall and only the strongest survive. With their strong empathy and intuition, the womb twin survivor will willingly voice the hidden negative emotions for his or her whole family, to the benefit of all concerned. This can be seen in the following questionnaire statements:-

Anger

I have a problem with expressing anger - either there is too much or too little 59.3%

I feel the pain of others as if it were my own 51.7%

For men, to be unreasonably angry, defensive or hostile can masquerade as a form of masculine strength. Such anger is driven by a fear of being perceived as inadequate, for to the womb twin survivor weakness means death. For women, to be angry is a powerful thing, and if she feels an inner sense of helplessness as she unconsciously identifies with her lost little twin, she will seek every opportunity to assert her power over others.

Transient, stress-related paranoid ideation or severe dissociative symptoms

Womb twin survivors are creative and imaginative people who inhabit an inner world of dreams. In their dreams is their lost twin so they are happy to dissociate from the world in order to search for it. They often create imaginary friends as children and may dream of their lost twin while asleep. For them the most important form of reality is their pre-birth experience.

Freud noticed that, for some individuals, two separate and contradictory versions of reality could co-exist and he called this phenomenon “splitting.” (Freud. S.1940) Some of the ways in which womb twin survivors dissociate or “split” are found among the questionnaire statements:

Dissociation

There are two very different sides to my character 55.2%

I have strong, inner imaginary life that I use as a coping mechanism 50.4%

I often feel torn in two between two decisions 51.8%

I make a lot of effort to protect my privacy 38%

I am always feeling paranoid about silly things 32%

I think I am psychic 27%

I spend a lot of time talking to myself in a mirror 18%

A sense of toxic shame

It has been thought that BPD is based in an overwhelming shame response. (M. Crowe 2004) Shame is also a major feature in the life of a womb twin survivor. There is a deep sense of being in some sense personally “wrong.” This may feel like being an “imposter” or “sham.” This can be interpreted simply as survivor guilt – a normal and natural response to being the survivor of a twin pregnancy. This sense of guilt was present in the questionnaire statements:

Shame

I have a prevailing sense of irrational guilt 38%

I am a perfectionist 35%

I feel personally responsible for events that have nothing to do with me 33%

I feel guilty about being alive at all 17%

Healing

Until a full explanation of the individual pre-birth experience is found, this carefully created fantasy, created out of vague pre-birth impressions, will seem more real than reality itself. Our research has revealed that intuitively calculating the precise nature of the pre-birth loss, and validating this with some personal research into embryology and foetal development, is a vital first step towards healing. It is a process of interpreting body memory, and can be facilitated by hypnosis and kinesiology. It is a necessarily uncertain process, subject to many errors and misjudgements, but once the right explanation is found the individual experiences a sense of deep peace and inner certainty.

Conclusion

The above strongly suggests that this so called “disorder” in its various manifestations may not be a mental health problem at all, but a rational, intelligent response to a rather unusual pre-birth situation. In the absence of a rational explanation, the etiology of Borderline Personality Disorder has remained elusive and hard to define, but a certain group of people presenting with a specific set of symptoms have been noticed, and given this label. The congruence between the symptoms of Borderline Personality Disorder and the psychological characteristics of womb twin survivors (i.e. the sole survivors of a twin or multiple pregnancy) who number 15% of the population, suggests that they may be one and the same. Mental health professionals, at the initial assessment stage, could use a checklist of signs and symptoms in the mother’s pregnancy in order to discover if individuals are womb twin survivors or not. If these patients found to be womb twin survivors, then the risk of a damaging misdiagnosis may be avoided and an appropriate treatment plan provided.

© Althea Hayton 2013

(This article may be reprinted, but only in its entirety and properly attributed. Thank you.)

References

American Psychiatric Association (1994) DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders American Psychiatric Press Inc.

Anand, D., M. J. Platt, et al. (2007). "Vanishing twin: a possible cause of cerebral impairment." Twin Res Hum Genet 10(1): 202-9.

Boklage, C. E. (1990). "Survival probability of human conceptions from fertilization to term." Int J Fertil 35(2): 75, 79-80, 81-94.

Chamberlain, D. B. (1998). The mind of your newborn baby. Berkeley, Calif., North Atlantic Books.

Chamberlain, D.B. (1980/1999). Reliability of birth memories: Evidence from mother and child pairs in hypnosis. In Selected Works of David Chamberlain, Journal of Prenatal Psychology and Health, 14(1-2), 19-29.

Freud. S. (1940). Splitting of the ego in the process of defence. Standard Edition 23:271-278. London: Hogarth Press, 1964

Harvey K. (2007) What vanishing twins may be telling us. In Hayton A (Ed) Untwinned: perspectives on the death of a twin before birth Wren Publications

Hayton A (Ed) 2008 A Silent Cry; womb twin survivors tell their stories Wren Publications

Huter, O., C. Brezinka, et al. (1990). "[The "vanishing twin"]." Geburtshilfe Frauenheilkd 50(12): 989-92.

Landy, H. J. and L. G. Keith (1998). "The vanishing twin: a review." Hum Reprod Update 4(2): 177-83.

Landy, H. J., L. Keith, et al. (1982). "The vanishing twin." Acta Genet Med Gemellol (Roma) 31(3-4): 179-94.

Landy, H. J., S. Weiner, et al. (1986). "The "vanishing twin": ultrasonographic assessment of fetal disappearance in the first trimester." Am J Obstet Gynecol 155(1): 14-9.

Langley M.L., (1994) Self-Management Therapy for Borderline Personality Disorder: A Therapist-Guided Approach Springer Publishing Company

Lloveras, E., J. M. Lecumberri, et al. (2001). "A female infant with a 46,XX/48,XY, +8, +10 karyotype in prenatal diagnosis: a 'vanishing twin' phenomenon?" Prenat Diagn 21(10): 896-7

M. Crowe (2004) Never good enough – part 1: shame or borderline personality disorder? Journal of Psychiatric & Mental Health Nursing vol 11 no 3 p. 327-334

Neisser, U. (2004) The Nature and Consequences of Very Early Memory Development. Developmental Review 24(1):154-158

Pharoah, P. O. (2002). "Neurological outcome in twins." Semin Neonatol 7(3): 223-30.

Pharoah, P. O. (2007). "Prevalence and pathogenesis of congenital anomalies in cerebral palsy." Arch Dis Child Fetal Neonatal Ed 92(6): F489-93.

Pharoah, P. O. and R. W. Cooke (1997). "A hypothesis for the aetiology of spastic cerebral palsy--the vanishing twin." Dev Med Child Neurol 39(5): 292-6.

Saidi, M. H. (1988). "First-trimester bleeding and the vanishing twin. A report of three cases." J Reprod Med 33(10): 831-4.

Wade, J. (1996). Changes of mind : a holonomic theory of the evolution of consciousness. Albany, State University of New York Press.

Woodward, J. (1998). The lone twin: a study in bereavement and loss. London, Free Association Books.

Zanarini M. C. et al (1998) Axis I Comorbidity of Borderline Personality Disorder Am J Psychiatry 155:1733-1739