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Where Have All the Mad Hysterics Gone?

Considerations of the Rise of Borderline as


Indicative of Contemporary Diagnostic Shortcomings
Eve Watson
Borderline, a contemporary diagnostic category in clinical psychiatry and psychoanalysis, was
first coined in 1938 by an American psychoanalyst, Adolph Stern to describe a group of
patients who lay on the border between the psychoses and the neuroses. Later, in 1987, it was
introduced by the American Psychiatric Association (APA) into the Diagnostic and
Statistical Manual (DSM) under the category of personality disorder, and in 1992, under the
ICD classification, the World Health Organisation classified Borderline Personality Disorders
(BPDs) as emotionally unstable personality disorders. As the signifier indicates, borderlines
are at the rim or edge of diagnostic taxonomy and encompasses a site of profound
overdetermination and are generally thought to occupy a confusing state somewhere between
neurosis, psychosis or perversion, as either pre- or pseudo-psychotics or increasingly less so,
mad unmanageable difficult hysterics. As a diagnostic category, it encompasses anxiety,
phobias, obsessive symptoms, depression, bizarre conversion symptoms, hypochondrias and
paranoid trends; multiple polymorphous perversion trends; pre-psychotic structure, schizoid
and hypomanic personality; addictions and character disorders such as the chaotic or impulseridden character and anti-social personality structures. Lacanian psychoanalysts might add to this
list perversions or perverse traits, actual neuroses as well as the phenomenon of what
Moncayo calls acting on the body, such as cutting, piercing and body scarification, as distinct
to the hysterics speaking with the body.
Borderline is thus a strange catchall, being like hysteria but sometimes with perverse elements;
while in other cases, it exhibits psychotic manifestations in the form of pananoias, delusions
and moments of dissociation or fugue. As Appignanesi notes, borderlines have in common a
certain wildness or impulsivity of action; unstable identities; difficulties regulating mood and
emotions; problems, often severe, in interpersonal relationships; they may sometimes to be a
danger to themselves or others and they dont, or perhaps cant follow the rules of everyday
behaviour that society sets down. In psychiatry, the diagnostic solution has been to place this
kind of patient into the field of the personality disorders, which captures something of the
perceived mad or bad conundrum thar is driven, according to Appignanesi, by both prevailing
governmental policy and psychiatric fashion. These patients would undoubtedly have been
categorized as deviant in earlier times. Various studies indicate a higher rate of borderline in
women but it is inconclusive as to whether this is because women tend to be more amenable to
seeking out a doctor and because women report higher rates of sexual abuse, which is
considered by some to be A special factor. But let us say that already, the question of women and
trauma form key interrogatives in an analysis of borderline, interrogatives that we might recall
interested Freud who first discerned a special link between hysteria and trauma and whose first
patients were unruly, mad, sometimes delusional women-hysterics.
The woman-hysteric of Freuds early writings was contemporaneous with the mad hysteric or
the hysterical psychotic of the early modern psychiatric taxonomy of hysteria. Pre-dating Freud
and providing the milieu into which he emerged, early modern psychiatrys turn to mental
causation in place of brain or somatic disorder was behind the notion of innate or acquired
hysterical constitution, WHICH framed the distinct categorization of hysteria and hysterical
psychosis. Throughout Kraepelins (1856-1926) eight editions of classificatory systems in his

textbook, hysteria migrates from hysterical madness as a general constitutional disorder to


hysteria as a reaction disorder, rooted in a hysterical personality. For Krafft-Ebing, who was
the first to divine hysterical psychosis, which he adapted from the German concept irresein,
which he in turn adapted from Morels conception of folie hystrique and hysterical madness,
hysteria is put as the initial cause of the affliction. It would take Freud to emancipate hysteria
from the view of it as an innate or acquired predisposition that explains all of the symptoms
presented by the patient, a therapeutically unusable approach.
For Freud, hysterics suffer from traumata, or more particularly, the psychic trace or imprint of a
trauma that has not been adequately abreacted. Analysis operates by getting the patient to recall
and re-experience the trauma and get rid of its strangulated affect and this causes the memory
to be stripped of its power, a wearing-away, as Freud puts it, that causes it to fall away into
forgetfulness, a transformation of an untamed memory into a tamed one. Freud, in the early
1890s, was more inclined to place hysteria, paranoia and psychosis along a continuum of
pathological defence, as he puts it in the aptly titled the Neuro-Psychoses of Defence, with
ego-defence working against an idea or a feeling that which aroused such distressing affect
that the subject decided to forget about it. Defence hysteria, along with hypnoid and retention
hysterias are acquired and are all determined by the repression of incompatible ideas which
leads to a splitting of the content of consciousness by what he terms an act of will. The
difference between hysteria, obsessional neurosis, phobia, psychosis and paranoia is the way
the repressed returns and the level of ego-defence employed against the unacceptable
representation. So while some writers (e.g. Macalpine and Hunter) argue that the early Freud
made no distinction between neurosis and psychosis, he clearly does so insofar as makes a
distinction between the types of repression involved. But he also indicates a certain intermixing
of hysteria and psychosis in some mad forms of hysteria, specifying that it is hypnoid
states that are determinative in hysterical psychosis. For example, in his 1893 lecture Some
Psychical Mechanisms of Hysterical Phenomena, Freud argues against the notion that
hysteria is a psychosis and notes that hysterics have moments of great clarity even if they are
sometimes interspersed with hypnoid states of insanity. Both Anna O and the case of Emmy
von N. demonstrated that some hysterics underwent periods of insanity while also having
periods in which there is an apparent clarity of mind along with the presence of critical
faculties. When Freud refers to amentia or hallucinatory or wishful psychosis, he does so
within the terms of hysteria and wish-fulfillment, citing the notion of an unbearable reality, a
loss which is rejected in a powerful fashion. Thus, we can trace the significance of hysterical
psychosis in Freuds early work both as an observable clinical phenomenon and as an indicator
of his as yet un-clarified distinction between neurosis and psychosis.
Katrin Libbrecht, in her brilliant study of hysterical psychosis, notes that as Freuds enthusiasm
for the treatment of psychoses decreases and his enthusiasm for the curability of hysteria
increases, the study of paranoia will ultimately become the basis for his second theory on the
psychoses, while his earlier ideas of amentia and hysterical psychoses become, aprs-coup,
good illustrations of his libido theory and the transference neuroses. The mad hysterics fade
away from Freuds writings, with the notable exception of the interesting 1915 piece A Case
of Paranoia Running Counter to Psychoanalytic Theory which details a woman hysteric who
develops a severe paranoia as a defence against loving a man which was itself a defence against
her Oedipal relation with her mother. In psychiatry, the varieties of hysterical madness, which
include hysterical mania, melancholia, hallucinatory confusion and paranoia were subsumed
within dementia praecox and then after that, within schizophrenia, led by Bleuler. A psychotic
state, even if temporary became automatically indicative of schizophrenia and the differential

diagnosis with hysteria disappears. By the publication of the DSM-I (1952), hysteria was
subsumed within psychosis where it lingered through the second edition, which mentions
hysterical neurosis and the hysterical personality, before it ultimately disappears.
Did the mad, lively, erudite and sometimes delusional hysterics in the Studies in Hysteria and
in the turn-of-the-century psychiatric writings disappear because they were cured, or because
the illness ceased to exist, or did they become more neurotic or more psychotic, as the
prevailing fashion indicated? Lacanian psychoanalysts assert that far from having disappeared,
hysterics and mad hysterics are alive and well or rather demanding to be heard in the guise of
multiple personality, borderline personality disorders, and in post-traumatic stress disorders
and anxiety disorders which show affinities with both of the hysterical key indicators that are
trauma and amnesia. In effect, the place of the borderline within the prevailing paradigm is
more akin to a dumping site for the extra-paradigmatic, or extra-structural, not in such a way
that it seems to be effecting a questioning of the prevailing paradigms but rather as a boundary
outpost, a marker of limits, while paradoxically being a disorder without limits as well as
bespeaking poor or ineffective border management. Borderline may therefore be conceived as a
reaction to the overarching comprehensiveness of psychosis in psychiatry, as a noisy and
sometimes unruly challenge to the pre-dominating mode of evaluating the patients illness not
in terms of the broad clinical picture but in terms of diagnostic categories and behavioural
descriptions that have their basis in an assumption of psychosis caused by organic factors or
character disordered pre-psychosis.
Thus, the borderline, substituting for a rigorous use of a theoretical and clinical frame of
reference, serves as a compromise for hysteria patients. As hysteria is more prevalent in
women, it might explain the greater prevalence of borderline pathology in women. But the link
to hysteria also reminds us that silence, at least at the level of speech, is the hallmark of
hysteria. As Showalter puts it, its as if their tongues have been cut off and what talks isnt
heard because its the body that talks and man doesnt hear the body. We can also connect the
rise of the borderline with the notion of a pathogenic secret (that expresses itself symbolically
and involuntarily) that is evident in Freuds early work on hysteria. In his Preliminary
Communication, he links his thinking with Moritz Benedikt who was first to systematize the
knowledge of the pathogenic secret and its psychotherapy. In a series of publications between
1864 and 1895, Benedikt showed that the cause of many cases of hysteria lies in a painful
secret, usually lying in their sexual life which could be cured by the confession of the secret
and working out its related problems. In this respect, we could substitute the clinical field and
contemporary biological psychiatry for man and conceive of the borderline as returning her
body to the clinical gaze in highly symptomatic and therapeutically challenging ways that
bespeak a profound deafness and unwillingness to listen and listen well to what she is saying.
A Lacanian framework can help us to understand both the position and etiology of the
borderline. In the borderline, Aisling Campbell notes that there is a problem with the distance
between herself and the image and she is unable to maintain the three-dimensional Borromeantype border that should result from the interaction of the three registers of the real, symbolic
and imaginary. This brings with it a problem of consistency, a problem of both imaginary and
symbolic consistency as both registers defend poorly against the impress of the real. This can
be read as Lacans re-working of Freuds theory of defence, the manner and strength of which
Freud argued defined a hysterical, obsessional, paranoid or hallucinatory outcome. This lack of
border consistency leaves the subject both dependent on and terrified of the Other. This means

that an all-powerful Other can be extremely difficult for this subject to handle, who may react
be trying to project the unbearable drive onto the Other. Hence, for her, her image is too much,
while her relationships with the Other and with the others in her life are characterized by
imaginary battles. As Campbell puts it, the bar of the subject is constantly shifting within the
borderline psyche.
With a lack of balance between the real, symbolic and imaginary and with a tipping over into
one or the other, the borderline is left either feeling full of tension or emptiness and is driven to
force her division in order to solve the tension. Affects swing up and down and apparently at
random and are often projected onto others and it is as though she is missing a symptomatic
solution to the problem of existence. The drive remains partially unregulated which, at best, is
experienced as anxiety and at worst, indefinable tension, often leading to substance-abuse and
self-harm attempts to regulate it. This is an attempt by an unsuccessfully divided subject to
introduce a border between herself and her jouissance. The problem however is that these
actions remain at the border of the real and the imaginary and are bound to fail and therefore to
be repeated unless the symbolic is invoked in affect regulation, which is the symbolization of
senses into perceptions. This putting into words allows the patient to see the internal world as a
representation of reality.
The problem of representing the internal world is linked to problems at the mirror stage and
here a distinction can be drawn between the oral fixations of the severely symptomatic hysteric
and those pertaining to the mirror phase for the borderline or mad hysteric, although there are
sometimes oral fixations in play also for the borderline. Much depends on whether the loss in
question pertains to the a in the image or to imaginary castration, i.e. not having received the
object of love. In the assumption of the image, what escapes is the o-object [HERE IS WHERE
YOU USE O-OBECT, RATHER THAN OBJECT A PERHAPS IT IS MORE PRECISE,
HERE?] and it is precisely
the fact that there is a hole in the mirror image that makes the image hold, recalling what Lacan
says in RSI, I will say that for something to exist, there must be a holeit is around a hole
that existence suggests itself. The hole allows, as Campbell reminds us, the transformation of
the mirror image back into the ego so there is a pushing out and a taking in. The lack
therefore is not only part of the subject but part of the Other and this is what gives the subject
distance from her own mirror image and to be more than just reflected in the Other. For the
borderline, her image is dependent on the Other, the lack in the Other may be too much, or she
may have been called to answer the lack, so the taking-in and pushing out of imaginary and
symbolic armaments does not happen as it should.
We can map these ideas onto other psychoanalytic approaches that nearly always cite
identification or ego problems with borderline patients. John Frosch cites a preoccupation with
identity problems, with problems of identity diffusion and fragmentation which causes the self
to disappear and psychotic-like manifestations in object relations. Similarly, Kernberg writes
about the lack of the capacity to bring together the aggressively and libidinally determined self
and object images. The affective depth of reality, Lacan reminds us in The Family Complexes in
the Formation of the Individual (1938) is a product of the Oedipus complex. Here Lacan richly
conveys the extremely powerful affective resonances of the subjects captivation and fixation
by a tyrannical imaginary in his discussion of the fraternal complex. The ego retains the
ambiguous structure of the spectacle clearly seen in the situations of despotism, seduction and
parade, which gives form to sado-masochistic and scoptophilic drives (the desire to see and be

seen) which are essentially destructive of the other. Here lies the themes of the paranoid and
archaic egos such as filiation and usurpation, spoiliation, paranoid themes of intrusion,
splitting, the double and delusional transmutations of the body.
What helps to create the illusion of the completeness of the ego and brings together the partial
drives under the auspices of the body image is the phantasy which places the divided subject in
an imaginary relationship with the lost object which does not really exist at all. The phantasy
produces an Other who dissatisfies in place of the horror of disappearing into or being
annihilated by the Others enjoyment. A problem for the borderline is the relation to the
phantasy object, the defect or hole or a in the body image which is normally experienced as a
wound, and which in neurosis has to be mourned, is lacking in depth, abstraction and distance,
being what Moncayo refers to as the absence of an absence. The imaginary loss at the level of
the ideal-ego remains unsymbolised as it is with the aid of the Name-of-the-Father in neurosis.
Not only is there a failure of the mother to convey or presentify her own object-loss, that is
give her own object a to her child, or she makes [OR TO MAKE?] the child her own object, but
the failure to symbolize the necessary absence of the a in the specular image has the consequence
of causing the child to remain captivated by the ideal ego/alter ego/specular image of a sibling or
peer that will occupy the place of the ego for the subject.
This may not be that far from British analysts, Juliet Mitchell and Estella Welldon, who argue
that borderline is a form of female perversion and when women attack their own bodies by
self-mutilation, starvation or binging or by placing their bodies in relation to an abuser, they are
avenging themselves on a perverse or cruel mother, whose extension they are. The question of
disavowal here is foremost, as Moncayo notes, and it arises from the mothers alternating
avowal and disavowal of the fathers name, which the subject repeats towards the image. This
means that while in perversion there is the absence of the object a from the specular or ideal
body image, and in neurosis the object a is linked with the imaginary phallus under the
symbolic function of the castration complex, in borderline, there is a need to grieve the loss of
the object that didnt take place so what ultimately serves as a guarantor of normality is a
dialectic between the object a and the symbolic phallus, which is what supports the symbolic
dimension of the Oedipus complex.
For Lacan, the essential role of the Oedipus complex is to distinguish reality in terms of
providing pleasure and unpleasure and a sense of border is crucial in order to frame
experience in terms of inside and outside, in terms of reality and unreality. The turn to and
identification with the Name-of-the-Father is what depreciates the dependence on the rival and
provides symbolization for the hole in the image which in turns allows for the symbolization of
an object a that is not in the specular image of the ideal-ego. The contours or rim of the hole
come to be inscribed with the signifier, providing for the symbolic representation of the hole
that is not wholly tied to the image. If the subject is a border, a border that arises from the
imprint of the symbolic onto the subject which divides the subject between conscious and
unconscious, and the subjects relation to phantasy helps to stabilise the border, the
borderlines borders are like moveable tectonic plates constantly colliding with the object that is
the image of the object of the mothers desire. This image is either totally loved or totally hated
and is without symbolic mediation. It is crucial to get the borderline speaking, speaking about
image or the lack in the mother and especially the father (whose limits and boundaries are only
often partially internalized), rather than acting, acting which is often a cutting on the body
which is an attempt to install a border.

In conclusion, the notion of borderline takes into account the idea of border, of a certain fluidity
of categorization and structure, which presents a challenge both to the tautological and
containing effect of diagnosis and to extant diagnostic categories in both the psychiatric and
psychoanalytic fields. Arguably, the borderline is a product of contemporary diagnostic
limitations in psychiatry that exclude hysteria as a diagnostic category. The rise of the
borderline can also be understood as a reaction to the growing influence of psychotherapeutic
practices with their normalizing practices [EFFECTS? GOALS?]. For example, Leguil argues
that the borderline fights against normalization where psychoanalysis degrades itself to the level
of normative therapy and ignores the division of the subject. This is in line with Lacan who
asserted that the major flaw in psychoanalysis has been the neglect of the structural in favour of
the dynamic. Other writers such as the object-relationist Michael Robbins argue that no theory of
borderline personality organization is comprehensive enough and the emphasis on the primitive
aspects of splitting which pre-date object relations do not go far enough to explain the phenomena
like compliance, false-self behaviour and relational and other adaptive functions of the ego that
are indicative of problems in the field of object relations. Campbell argues that with the
borderline there may be a need for more diagnostic categories. For my part, I dont agree with the
idea of creating new diagnostic categories, which would include a new category for borderline.
Rather, I suggest that a return to Freuds early work on hysteria and hysterical psychosis, as well
as a re-invigoration of research into the rich material of the early modern dynamic psychiatric
writing provides a rich hunting ground and context for contemporary forms of hysteria.
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