Sylvia Plath and the depression continuum

Abstract

The use made by Dr Cooper (June 2003 JRSM1) of Sylvia Plath's case history to explore psychiatric nosology is interesting and his conclusion that she suffered from borderline personality disorder (BPD) is convincing. But there are further diagnostic issues to be considered. I have argued elsewhere2 that reliance on the DSM list of traits to diagnose BPD fails to highlight a central characteristic of these patients, namely a form of instability which reflects the alternating operation of one or other of a small range of patterns of interpersonal and intrapersonal functioning. This fragmented structure is initiated, in those genetically prone, by childhood exposure to psychologically unmanageable experiences. Subsequently, perceptions, experiences or thoughts of rejection or of threat can activate this dissociation. A relatively small range of constituent states is met with in borderline patients3 and these are most usefully described in terms of the relationship patterns determining interpersonal perceptions and behaviour and self attitudes and management. The 'overresponsiveness to daily experiences' and 'heightened reactivity to life's ups-and-downs' which Plath and other borderline people manifest are more accurately described by this 'multiple self states model' (MSSM). Four commonly encountered borderline states are evident in the case of Plath. The first is a state found in all borderline patients in which relationships are of the form 'abusing/abandoning to abused/abandoned'. Plath was over reactive to hints of rejection and could herself switch suddenly from closeness to abusing and rejecting others and harming herself. Second, striving can lead to real success, as with Plath, and praise can compensate for feeling unloved. But any hint of criticism or rejection can provoke catastrophic reactions, representing a switch from the 'striving–praising' to the 'abusing–abused' pattern, as evident in her self-harm and attempted suicide at Harvard. Third, intense relationships with idealized others can support phases of wellbeing and creativity but the actual or perceived shortcomings or betrayals of the other provoke switches into abusive patterns; this was manifest in her violently oscillating relationship with Hughes, well described in his Birthday Letters. Fourth, Plath's poetry can be seen to be preoccupied with 'borderline' themes (loss, violence and contradictory experiences of the self) but these do not necessarily generate poetry. The association of instability with creativity is probably linked with another borderline trait, the capacity for intense concentration. This represents a dissociation from current surroundings and preoccupations, even when these are difficult, as they were while she was writing Ariel. The distinction between bipolar disorders and borderline states may be less clear than Cooper suggests. Borderline states vary in the frequency with which they are mobilized and in their duration, and what provokes switches may not be apparent. The contrasting moods of bipolar patients are accompanied by changes in self-management and relationship patterns and their state switches may be reactive to life events. Borderline patients may be helped by mood stabilizing drugs and bipolar patients may be helped by psychotherapy.4 I would suggest that, in comparing the two conditions, the model of BPD needs to incorporate the structural understandings of the MSSM.