How Does It Feel To Have A Disturbed Ide

Journal of Personality Disorders, 36(1), 40–69, 2022

© 2022 The Guilford Press

HOW DOES IT FEEL TO HAVE A

DISTURBED IDENTITY? THE PHENOMENOLOGY
OF IDENTITY DIFFUSION IN PATIENTS
WITH BORDERLINE PERSONALITY DISORDER:
A QUALITATIVE STUDY
Carsten R. Jørgensen, PhD, and Rikke Bøye, MSc
Identity diffusion is one of the defining characteristics of borderline

personality disorder (BPD). Given its central importance in the
formal diagnostic criteria for personality disorders, identity diffusion
is remarkably under-researched. In particular, our knowledge of the
phenomenology of identity diffusion needs to be improved. This study
is based on semistructured interviews with 16 younger women SCID-5–
diagnosed with BPD. All interviews were analyzed using the interpretative
phenomenological analysis approach. On the basis of this analysis, the
patients’ descriptions of how identity diffusion manifests itself in their
subjective experience are classified into nine categories: disintegrated
self-image; using various façades to stabilize the self; painful feelings of
the self as broken; feeling that the self does not fit in; inner emptiness; “I
don’t know what I want”; great need for attention from others to stabilize
identity; feeling unable to handle interpersonal relationships; and using sex
to distract the self and regulate painful self-states.
Keywords: identity disturbance, borderline personality disorder,

qualitative study, patient perspective, phenomenology, sexual behavior
Borderline personality disorder (BPD) is a complex psychiatric condition with

an estimated mean prevalence of 1.4% in the general population (Morgan
& Zimmerman, 2018), about 10% in patients seen in outpatient clinics, and
approximately 20% among inpatients. Formally, severe identity disturbance is
one of the defining characteristics of BPD in the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric
Association [APA], 2013) and ICD-10 (World Health Organization [WHO],
1992). In ICD-11 (WHO, 2019), pervasive disturbance in the functioning
aspects of the self, including stability and coherence of the subjective sense of
identity, is elevated to a central criterion in determining the level of disturbance
in personality organization in general (Bach & First, 2018). Moreover, identity
From Department of Psychology, Aarhus University, Aarhus, Denmark (C. R. J.); and Clinic for Personality
Disorders and Suicide Prevention, Aarhus University Hospital, Skejby, Denmark (R. B.).
Address correspondence to Prof. Carsten René Jørgensen, Department of Psychology, Aarhus University,
Bartholins Allé 11, DK-8000 Aarhus C, Denmark. E-mail: [email protected]
40
PHENOMENOLOGY OF IDENTITY DIFFUSION 41
disturbance is also one of the qualifiers for the specified borderline pattern
in ICD-11. Similarly, the alternative DSM-5 model for personality disorders
lists identity disturbance as one of only four central criteria for pathology in
personality functioning in general. Identity disturbance is thus elevated from
a feature of BPD to a core construct in all personality disorders. In addition
to this, and more specifically, “markedly impoverished, poorly developed, or
unstable self-image, often associated with excessive self-criticism, chronic feel-
ings of emptiness” (APA, 2013, p. 766) is also one of the essential diagnostic
criteria for BPD in the alternative DSM-5 model. In the DSM-5 Level of Per-
sonality Functioning Scale, identity problems are constructed as dimensional,
ranging from little or no impairment with accurate self-appraisal to extreme
impairment with virtual absence of sense of agency, distorted self-image, and
confused boundaries between self and others. Kernberg’s theory of personal-
ity organization designates severe disturbance in identity functioning as the
crucial criterion for differentiating severe personality disorders or borderline
personality organization from milder forms of personality disorders or neu-
rotic personality organization (Kernberg & Caligor, 2005). Identity distur-
bance is highly important in differential diagnostics, including the difficult
differentiation of BPD from bipolar disorder (Bayes & Parker, 2019, 2020).
But what exactly does it involve to have a severely disturbed identity, how
is it experienced by people with BPD, and how does it affect deeper aspects
of their daily lives? Questions such as these are highly important and at best
only incompletely answered.
NORMAL IDENTITY
Theoretically, a high level of identity integration is an essential aspect of psy-

chological resilience. A consolidated, stable, and flexible identity “constitutes
an inner resource that is important for self-regulation and the ability to navi-
gate in a complex social world” (Jørgensen, 2018, p. 107). It has also been
argued that the ability to maintain a unique sense of self and a stable self-image
(“who I am and what I stand for”)—even under stress—is related to the abil-
ity to handle stressful life events and strain in general (Feenstra et al., 2014).
Normal and consolidated identity involves a stable and coherent self-
image; having a sense of an inner core, continuity, and sameness of the self over
time and across different social contexts; and the capability to make stable
emotional commitments to other people and to self-defining social groups and
communities. This also includes “commitment to intimate mature relations in
which sex and love need not be split off from each other” (Kernberg, 2018,
p. 10) in addition to experienced self-distinctiveness, seeing the self as unique
and distinct from others. Kernberg (2016) has argued that identity and char-
acter are mutually complementary expressions of the organization of inner
psychic life, where identity development is the subjective aspect of the dynamic
organization of character. Phenomenologically, normal identity is reflected in
nuanced, coherent, and realistic answers to the fundamental question “Who
am I?” and associated questions, such as “How am I different from others?,”
“What are my basic norms, goals, and needs?,” and “What social groups and
42 JØRGENSEN AND BØYE
communities am I part of and identified with?” (Jørgensen, 2018, p. 107).

Persons with a normally developed or mature identity “have the capacity to
relate to others as separate and autonomous objects” (Akhtar & Samuel, 1996,
p. 261)—a capacity that is highly important to evaluate diagnostically and
essential for several aspects of psychotherapeutic work, one of them being how
it facilitates the development of a therapeutic alliance. This ability is typically
compromised in patients with identity diffusion.
IDENTITY DIFFUSION
Kernberg (1984) defined identity diffusion as the result of disordered and

insufficiently integrated representations of the self and others. As Fuchs (2007)
describes it, people with identity diffusion “lack the strength to establish a
coherent self-concept,” resulting in painful and unpredictable “switching from
one present to the next and being totally identified with their momentary state
of affect” (p. 381). Fuchs adds that one might see this as “temporal splitting of
the self that tends to exclude past and future” (p. 381). Completely identified
with their momentary state of mind and unable to draw on experiences from
the past, they have difficulty experiencing agency, stumbling unreflectively
from one present moment to the next.
Some of the most important and elaborated theoretical and clinically
meaningful descriptions of severe identity disturbance are presented in the
psychoanalytic literature (Akhtar, 1984; Akhtar & Samuel, 1996; Kernberg,
1984). Akhtar (1984) proposed six core features of pathological identity dif-
fusion: (1) contradictory character traits and inconsistencies in behavior, (2)
temporal discontinuity in subjective sense of self/identity, (3) inauthenticity
or absence of depth and genuineness in appearance and behavior, (4) feelings
of inner emptiness, (5) subjective uncertainty regarding one’s own gender and
sexual orientation, and (6) moral relativism and contradictory norms and
values. In addition to these features, identity diffusion is often manifested in
feelings of being disconnected from others, feeling excluded from social com-
munities, deeply felt inauthenticity and confusion about “who I really am,” and
a diffuse fear of losing one’s personal identity if relationships with significant
others are disrupted. For a more elaborated definition and discussion of the
concept of identity and identity diffusion, see Jørgensen 2010 and 2018.
PREVIOUS STUDIES
Given the central nature of identity disturbance in BPD, empirical research

on the subject is remarkably sparse and restricted by the absence of a consen-
sual definition of identity and identity disturbance. A number of quantitative
studies, based mainly on questionnaires and rating scales designed to capture
aspects of identity functioning, have found that identity diffusion is related to
BPD (Jørgensen, 2009), but also to other personality disorders and psychiatric
problems. Higher scores on measures of identity diffusion predict increased
levels of general psychiatric symptoms and interpersonal problems (Lowyck
et al., 2013), and (fairly primitive) self-report measures of identity diffusion

correlate with emotion dysregulation (impulsivity), not only in BPD patients
but also in other psychiatric populations (Neacsiu et al., 2015). BPD patients
with a high level of identity diffusion have greater general symptom severity
compared with patients who have lower levels of identity diffusion (Sollberger
et al., 2012). Identity diffusion is thus a potentially important indicator of the
general level of disturbance.
Theoretically, identity diffusion can be linked to impairments in men-
talizing. Mentalization is “the ability to understand actions by other people
and oneself in terms of thoughts, feelings, wishes, and desires” (Bateman &
Fonagy, 2016, p. 3), and one could argue that this mental ability or process
“gives us the sense of continuity and control that generates the subjective sense
of agency or ‘I-ness’ which is at the very core of a sense of identity” (Bateman
& Fonagy, 2006, p. 4; see also Jørgensen, 2010, pp. 351f). Highly significant
correlations have been found in BPD between, on the one hand, mentalizing
impairment and interpersonal problems and, on the other hand, identity dif-
fusion (r = .61 and r = .57, respectively; p < .001; Meulemeester et al., 2017).
Moreover, identity diffusion has been found to fully mediate the relationship
between impairments in mentalizing and relational difficulties (Meulemeester
et al., 2017; see also Fonagy et al., 2016), suggesting that identity diffusion
could play an important role in most essential aspects of BPD. On the basis
of narrative analyses of life story interviews, Adler et al. (2012, p. 509) found
that persons with BPD features (not full BPD) have problems constructing a
coherent self-narrative that features an agentic protagonist who is able to fulfill
his or her communal needs; the authors interpret these deficits as manifesta-
tions of identity diffusion. Similarly, in a study of how BPD patients described
their own and their parents’ life stories compared with normal controls, Lind
et al. (2018, 2019) found that the BPD group provided descriptions with more
negative emotional content and fewer themes of agency and communion fulfill-
ment. In addition, the BPD patients’ descriptions of their parents’ life stories
were characterized by lower levels of complexity and a higher likelihood of
self–other confusion, all of which are possible indications of identity-related
problems.
On the basis of factor analyses of therapist ratings of theoretically derived
indicators of identity functioning in psychotherapy patients, Wilkinson-Ryan
and Westen (2000) identified four factors in severe identity disturbance: (1)
role absorption (tendency to define the self in terms of a single role or cause);
(2) subjective sense of a lack of self-coherence; (3) objective inconsistency in
thoughts, feelings, and behavior; and (4) lack of commitment to norms and
values. All four factors differentiated BPD patients from patients with other
personality disorders as well as from nonpsychotic patients with no PD. Pain-
ful incoherence was most strongly related to BPD, making further exploration
of this aspect of identity diffusion particularly important. The main focus of
this study was clinician assumptions about identity disturbance in patients
with personality disorders, not efforts to gain in-depth understanding of the
affected patients’ subjective experience of identity diffusion. In conclusion,
we need more clinically meaningful and rich depictions of identity diffusion
than presently exist (Westen et al., 2011, p. 312).
So far, the predominant view has been that because of “lack of insight into
themselves” (Wilkinson-Ryan & Westen 2000, p. 539) or “limited psychologi-
cal mindedness” (Neacsiu et al., 2015, p. 357), people with PD, particularly
BPD, are unable to provide valid information about complex aspects of their
inner psychological life, such as identity. This view is not adequate. In our
view, it is highly interesting, clinically relevant, and important to consider and
respect how severe identity disturbance is actually expressed in the subjective
experience of people with severe PD, including BPD. Our need for deeper
insight into the phenomenology of identity diffusion cannot be adequately
met with the use of standardized questionnaires and therapist ratings of BPD
patients’ identity problems from an outside perspective alone—we also need
the insights that can be gained from well-structured conversations with people
living with BPD.
Very few studies have presented empirically based in-depth descriptions of
the phenomenology of identity and severe identity disturbance. To some extent,
this scarcity can be explained by the significant difficulties in operationalizing,
quantifying, and capturing the essence of identity and identity diffusion. How-
ever, qualitative studies can enable a deeper and more nuanced understand-
ing of the phenomenology of identity disturbance—how identity diffusion
manifests itself in the subjective experience and inner life of people with PD.
“Identity and other aspects of human subjectivity should not be excluded from
psychology and psychiatry just because they are difficult to operationalize and
research using traditional quantitative methods. To understand identity, we
need to focus on subjective experience” (Jørgensen 2018, p. 108). We need
qualitative studies focusing on more subtle aspects of individual subjective
experience. As argued by Wurmser (2019, p. 16), psychotherapy is the art of
the specific; scientifically, universal laws and concepts are highly important,
but when it comes to our work as psychotherapists, these universal theories
and concepts are empty if they are not filled with specific content related to
human subjective experience.
Despite the important role of identity diffusion in PD, qualitative research
on this experience, including how it manifests itself in patients’ subjective
lives, remains sparse. In fact, to our knowledge, only two studies exist. In one
study, thematic analyses of life story interviews were used to describe elements
of identity disturbance in five women with symptoms of BPD (Agnew et al.,
2016). A second study, of the self-image of patients with BPD (n = 12), using
a structured interview focusing on self-perception, also has some relevance
in aiding our understanding of identity diffusion. In this study, BPD patients,
not surprisingly, showed difficulties with describing themselves coherently and
their self-descriptions were superficial (Dammann et al., 2011).
THE CURRENT STUDY
The main focus of this study is how severe identity disturbance is manifested
in the subjective experience of the self and of the self in relation to others in
women diagnosed with BPD. In light of the interpretive phenomenological
analysis (IPA) of 16 qualitative in-depth interviews (see below), we address
the following question: How do young women with BPD describe the way
identity diffusion is manifested in their subjective experience, behavior, and
daily life? Certain important related questions—such as the historical and
psychological etiology of identity diffusion and whether identity disturbance
is a unitary phenomenon, distinguishes BPD from other personality disorders,
and is related to general level of disturbance in patients with PD—are not
addressed in this study.
To our knowledge, the study presented here is the first idiographic study
concerned with the particular identity-related problems in people with BPD
that aims to unfold how identity diffusion finds expression in the subjective
experience of individual BPD patients. We attempt to demonstrate the existence
of specific experiences and manifestations of identity diffusion, not incidence.
The main objective is to present nuanced descriptions of how identity dif-
fusion is experienced by individual patients with BPD, not to offer explana-
tory accounts of identity diffusion and its etiology. Compared with earlier
qualitative studies (see above), our study is based on fully diagnosed BPD
patients (not just persons with BPD features; cf. Adler et al., 2012), and our
main focus is on the specific manifestation of identity diffusion in the subjec-
tive experiences and daily lives of the participating women, not just on how
aspects of identity diffusion might manifest more indirectly in certain aspects
of the content, emotional valence, or (compromised) structure of life story
interviews with a much broader focus on overall life stories and life story
chapters (cf. Adler et al., 2012; Lind et al., 2019). Narrative perspectives on
identity have made important contributions to our understanding of selected
aspects of identity, but in our view, identity and identity diffusion cannot be
reduced to self-narratives and life stories. We also need studies, such as the one
presented here, that focus specifically on deeper and more structural aspects
of human identity and identity diffusion.
PARTICIPANTS
Sixteen adult women participated in the study, mean age 27.6 years (SD = 6.2
years, range 21–43 years). To rule out possible gender- and age-related dif-
ferences in how identity diffusion is manifested, we decided to include only
younger women in the study. All patients were recruited from the Clinic for
Personality Disorders and Suicide Prevention, Aarhus University Hospital, and
were diagnosed with BPD. Diagnoses were based on SCID-5 interviews (First
et al., 2017) conducted by experienced psychologists systematically trained and
with extensive experience in the use of the interview (for an earlier study of the
reliability of SCID-5 diagnosis from the clinic, see Jørgensen et al., 2013). All
patients met the DSM-5 BPD diagnostic criteria for BPD, including the BPD
criteria for disturbed identity; two patients had a comorbid narcissistic person-
ality disorder, and three had salient narcissistic traits (meeting four criteria of
NPD). Possible comorbid symptom disorders were not systematically assessed.
Based on the normal clinical assessment conducted when patients enter the
clinic, two of the participants were diagnosed with recurrent moderate depres-
sion, one with obsessive-compulsive disorder, and one with moderate cannabis
use disorder. Participation was voluntary, and all patients had the right to with-
draw from the study at any time during the course of the study. All participants
were individually informed (verbally and in writing) about the study objectives
and signed an informed consent form. Because no intervention was involved,
the study did not need approval from the Danish Scientific Ethical Committee.
However, the study was registered and approved by the Danish Data Protec-
tion Agency, Central Denmark Region (Registration no.: 1-16-02-217-20).
All participants were asked to answer two questionnaires designed to
assess identity disturbance: the Inventory of Personality Organization (IPO;
Lenzenweger et al., 2001) and the Self-Concept and Identity Measure (SCIM;
Kaufman et al., 2015); both instruments have good psychometric proper-
ties. The SCIM is a 30-item self-report measure developed to assess clinically
relevant aspects of identity disturbance, the IPO is an 83-item questionnaire
developed to assess aspects of personality organization, including level of
identity diffusion. The Symptom Checklist-92 (SCL-92) questionnaire was
administered to assess general symptom level (Derogatis, 1983). The SCL-92
is a well-established 92-item self-report questionnaire developed to assess
symptom level on various dimensions. The three questionnaires were admin-
istered to provide a preliminary assessment of the general levels of disturbance
and identity diffusion in the participating patients, based on quantitative
self-report measures.
METHOD
All interviews were conducted by the first author using a semistructured inter-
view guide. Based on comprehensive analyses of the identity concept and the
concept of identity diffusion (see Jørgensen, 2008, 2018, 2020), prior efforts
to delineate the central aspects of identity diffusion (Akhtar, 1984; Kernberg &
Caligor, 2005), the conceptualization of identity disturbance in DSM-5 (APAs,
2013), and existing empirical studies of identity diffusion (Dammann et al.,
2011; Wilkinson-Ryan & Westen, 2000), we constructed an interview guide
with eight main questions and a number of possible follow-up questions, all
of them focusing on what can be conceptualized as the main manifestations
of identity disturbance. In simplified terms, Akhtar’s (1984) subcategories of
identity diffusion were part of the inspiration for questions 1–5 and 8; the
DSM-5 conceptualization of identity disturbance was integrated into ques-
tions 1, 2, 5, and 6; the analytic subcategories of identity diffusion presented
by Wilkinson-Ryan and Westen (2000) are part of the theoretical and empiri-
cal background of questions 5–7; and so forth (see Table 1; the full interview
guide can be requested from the first author). Most of the existing conceptions
of identity diffusion are relatively abstract and general in nature, and thus this
study could also be interpreted as an effort to specify and understand what these
conceptualizations refer to more specifically—or how they are manifested—in
the subjective experience and lived lives of women diagnosed with BPD.
Our primary intention was to construct an interview guide based upon
open-minded questions about the participating patients’ self-concept and
identity-related problems in their daily lives, communicating genuine interest
TABLE 1. Questions From the Interview Guide

1. If you wanted me to know you as well as possible in 5–10 minutes, how would you describe yourself to give
me an idea about who you are as a person?
Examples of possible follow-up questions: Would you say that your experience of who you are is stable, or
does it fluctuate a lot? Are you sometimes confused about who you really are? Do you sometimes feel empty
inside, as if you have no inner core; that you are like an empty shell?
2. Could you tell me a little about how you feel when you are together with other people?
Examples of possible follow-up questions: Do you sometimes put on a façade, play a game, or act like
you are a different kind of person than you really are? When you are in intimate emotional or physical contact
with others, how does that make you feel?
3. How does it feel to be you?
Examples of possible follow-up questions: How do you feel in your role as a woman? Do you feel
comfortable in your body?
4. How do you feel when you are alone?
Examples of possible follow-up questions: Do you enjoy being alone or does it make you feel
uncomfortable? Do you sometimes feel lonely, even when you are with other people?
5. Could you tell me a little about what is important for you in your life; what goals, norms, and values are
important to you?
Examples of possible follow-up questions: Are you having trouble figuring out what is important to you? Is
it difficult for you to make up your mind and choose among different options?
6. How do you see your own future? What do imagine your life will be like 5 or 10 years from now?
Examples of possible follow-up questions: Are you a person who is strongly committed to long-term goals?
7. How do you see yourself in relation to social groups and communities? Are you part of one or more social
groups/communities, or do you feel you are different from others, like a lone wolf, isolated or excluded from
social communities?
Examples of possible follow-up questions: Do you feel you’re part of a group where you can be yourself
and feel accepted as an important group member? Do you have a place that feels like home, where you can
be yourself, or do you feel homeless?
8. Could you tell me what sex means to you and what it means in your life. How is your sex life? Please let me
know if you don’t want to answer this question.
Examples of possible follow-up questions: Do you primarily have sex with people that you know well and
have feelings for—or do you try to keep those things separate? Do you sometimes use sex as a way to get in
contact with other people or as a way of coping with difficult feelings?
and curiosity while at the same time asking for specific examples of how their
identity diffusion and compromised self-concept are manifested in subjective
experience. We asked the women how they would describe themselves, how it
feels to be in their shoes, and how they feel when they are, respectively, alone
and together with others. We also tried to get an idea of how the participat-
ing women see themselves in relation to social groups (e.g., as well-integrated
members, socially marginalized), what (if anything) they see as important in
their lives and how they imagine their future (if they do).
Not all significant facets of identity diffusion can be elicited to the same
degree through quick and formal questioning, and the interviews were con-
ducted as open-ended conversations focusing on identity-related aspects of
the patients’ subjective experience of themselves and relationships with others.
This open conversation format is well suited for establishing a good rapport
with informants in general and with BPD patients in particular, which is a
precondition for the kind of trust and psychological contact that is necessary
for the participants to allow us to gain insight into more intimate and vulner-
able aspects of their inner subjective life. Our goal was to establish a subject–
subject relationship, where the interviewer is eager to understand “how it is
to be you” (the patient) and how a disturbed identity manifests itself in the
patient’s subjective experience. Participants were continually asked to offer
specific examples of how they had experienced selected aspects of identity
diffusion in various situations.
Participants were informed that the interview would take up to 2 hours
and focus on how they experience themselves; how they feel when they are
alone or with other people, respectively; how they see themselves in relation
to social groups; and, finally, how they experience selected aspects of their
sexuality. The participants were free to end the interview at any time and
could ask for a break if needed. No interview was ended prematurely; one
participant asked for a 5-minute break. Interviews were audio-recorded and
transcribed verbatim. Average duration of the interviews was 2 hours and 5
minutes (SD = 19.2 min., range 95–155 min.).
DATA ANALYSIS
All interviews were analyzed by the first author, first case by case, then across
cases in a search for any recurrent or related themes and common experiences
associated with identity and identity disturbance. This was done in accordance
with the IPA method. IPA represents an approach to qualitative inquiry and
is an elaborated method for structured content (micro)analysis of qualitative
data, including semistructured qualitative interviews as used in this study.
Methodologically, IPA is “concerned with the detailed examination of human
lived experience. . . . in a way which as far as possible enables that experience
to be expressed in its own terms rather than according to predefined category
systems” (Smith et al., 2009, p. 32). The study’s methodological integrity is
thus supported by a hermeneutic and phenomenological approach in line with
our intention of getting as close as possible to the subjective experience of the
participating women diagnosed with BPD.
IPA has six consecutive steps (see Smith et al., 2009). First, one reads,
rereads, and listens to the interviews case by case in order to immerse oneself
in the patient’s narrated experiences and to obtain an in-depth understand-
ing of the material while sorting the material into general categories such as
“feeling disconnected from social communities” or “I don’t know who I am.”
In this initial phase, the researcher proceeds slowly and tries to avoid the pro-
pensity for quick and superficial interpretation of the material. The goal is to
access the inner world and subjective experience of the individual participant.
Step 2 involves a closer reading of the transcript with the aim of producing
a comprehensive set of exploratory notes, reflections, and comments on all
relevant aspects of the interview. The primary aim in this phase of the analysis
is to capture and crystallize key aspects of the content while staying close to
the patient’s explicit meaning. Each utterance is looked at separately: What
is the participant saying here that is of relevance for her experienced identity
problems? (Smith et al., 2009, pp. 82ff).
The main task of Step 3 is to capture the essential content of the material,
searching for and naming recurrent themes and experiences in each individual
case. In this phase, the volume of detail in the transcript and exploratory
notes is reduced substantially, while the complexity of the material and the
grounding of the named themes in the exploratory notes and in the transcript
are maintained as far as possible (Smith et al., 2009, pp. 91f). Step 4 involves
searching for connections and commonalities across emerging themes in the
individual interview. In this process, some of the themes extracted from the
preceding steps are integrated into larger superordinate themes, while others
are discarded, renamed, or reframed. Step 5 involves moving on to the next case
and successively repeating the first four steps for each of the sixteen interviews.
In accordance with IPA’s idiographic perspective, all participants are treated
on their own terms in an effort to do justice to their respective individuality
or uniqueness. Finally, in Step 6, the researcher looks for common themes and
experiences across all 16 cases included in this study. Again, some themes are
discarded while others—the most frequent, most potent, and most intimately
related—are integrated, to some extent relabeled, and given descriptive names
that capture the essence of the theme and subjective experience (Smith et al.,
2009, pp. 101ff). This is a more creative and interpretative task, which involves
moving back and forth among all the cases, including efforts to understand one
participant’s statement(s) in light of related experiences formulated by other
participants. Throughout the process, all formulated themes are grounded in
specific excerpts from the transcribed interview material in order to stay as
close as possible to the phenomenology of the participating patients’ subjec-
tive experience.
To illustrate the analytic process, the following is a sample statement by
one of the participants, who speaks about her self-understanding: “Well, we
all have different roles that we play in interactions with other people. You’re
one person with your grandmother and another with your friends. For me, it
has a lot to do with how I feel. If feel . . . good, I am . . . , no, if I feel bad, I am
the funniest person in the world. I take on the role of class clown, cracking
one joke after another, using it as a defense mechanism.” In the first analytic
phase, we note that the interviewee’s self fluctuates, depending on who she
is with and how she feels. In the next phase, the interview fragment is clas-
sified into two different categories: “fluctuating self-concept” and “façade as
defense mechanism.” In concluding our analysis of this particular individual,
the utterance is classified primarily into the category of “I don’t know who I
am; fluctuating self-concept” and secondarily into the category of “fluctuat-
ing self-appearance.” In the final cross-case analysis, the fragment is included
in two overarching analytic categories: “I don’t know who I am; fluctuating
and disintegrated self-image” and “‘Fake it till you make it’; using masks and
façades to stabilize the self” (see below).
RESULTS
In terms of the more descriptive characteristics of the participants, only 12 of

the participating patients answered the questionnaires. The Average SCL-92
Global Severity Index score was 1.97 (SD = .66), indicating a relatively severe
level of disturbance in the participating group of women (cutoff for pathol-
ogy = 0.8). In terms of average level of identity disturbance, the mean score
on the IPO scale for identity diffusion was 78.4 (SD = 10.2), demonstrating
a very high level of identity disturbance (Lenzenweger et al., 2001). Similarly,
the average scores on the SCIM scales for identity disturbance and lacking
identity were very high: 46.8 (SD = 13.7) and 32.4 (SD = 8.5), respectively
(Kaufman et al., 2015).
IPA yielded nine superordinate themes. Most of the participants endorsed
and contributed to all nine themes, in a few cases only implicitly (e.g., not
explicitly saying they feel lonely but appearing to demonstrate the feeling
in telling us they have no or very few friends and would like to have more
friends but do not know how to accomplish that). A few of the women made
so few statements about individual themes that we refrained from classifying
them (see Table 2). In two cases, the participant said explicitly that she did
not experience a specific problem. One woman told us that she felt very well
integrated in a social community (Category 4). Another women stated that
she did not experience any problems related to her sex life (Category 9). In
the following, we will describe the nine categories derived from the interviews.
1. “I DON’T KNOW WHO I AM”;

FLUCTUATING AND DISINTEGRATED SELF-IMAGE
All participants reported a painful experience of not knowing who they are,
not having an inner core, or feeling that “there is no me” and thus being unable
to describe who they are. One of the women said, “This is exactly my prob-
lem [and] it’s terribly confusing, not being able to navigate who I am, what I
really truly think and feel, and what my view is on things” [W14] (numbers
in brackets refer to participant number). Similarly, a participant said that she
cannot figure out whether “what I am saying is something I really mean; if
what I feel is something I really feel. The thoughts I have in my head [about
who I am], are they even true, really?” [W6]. Another participant articulated
the problem as follows: “I don’t feel that I can wholeheartedly say one single
thing [about who I am]” [W15]. A few of the women seemed to have a notion
TABLE 2. Frequency of Recurrent Themes/Subjectively Perceived Problem Areas

(n = Number of Patients Classified in Each Category)
Theme/category Explicitly present Implicitly present Not present Insufficient data
1: Don’t know who I am 16
2: Using façades 14 1 1
3: Self is broken 16
4: Self does not fit in 13 1 2
5: Inner emptiness 11 5
6: Don’t know what I want 13 2 1
7: Contact to stabilize identity 13 1 2
8: Relational paradox 15 1
9: Sex as self-regulation 13 2 1
Note. Explicitly present: n = number of participants explicitly articulating this as a subjectively perceived problem.
Implicitly present: participants implicitly communicating this as a problem. Not present: participants explicitly
denying that this is a problem area. Insufficient data: data on the theme are inconclusive/cannot classify.
of a hidden self, but at the same time they felt unable to find or get in contact
with this inner core or self: “Every part of me is hidden, and because they
are so well hidden I don’t know, who I am” [W3]. However, most of them
implicitly or explicitly appeared to agree with this woman when she said, “I
have never known who I am” and that she does not know “how it feels to
know who I am” [W13].
Some of the women were primarily preoccupied with not knowing who
they are, in some cases not knowing who they are behind the different masks
or façades they present to others and to the world in general (see Category 2).
This is an experience of being defined by and always accommodating others to
the extent that they do not know or have lost track of who they “really are.”
Others were more concerned with how their self and self-experience fluctuate
in ways that are highly confusing and dependent on either their momentary
and highly transitory emotional state or whom they are with, that is, their
immediate social context. One of the women said: “It is really difficult for me
to answer that question [about who I am], because I feel it is so dependent
on the mood I’m in and on the situation and the people around me” [W12].
Several participants reported that their momentary self-understanding is highly
dependent on their immediate mood: “I am my feelings” (or the feeling that
dominates in the here-and-now), and “when I am in a good mood, I’m unable
to remember that I felt bad, and vice versa” [W4]. “When you’re really con-
fused in your head about who you are, it can be like, well, this is how I feel
right now, so this is just how I am at the moment. It’s like, I am the feeling, if
you can put it that way” [W16]. One of the women, Katrine (name changed),
expressed her difficulty in grasping who she is as follows:
When I was in treatment for alcohol abuse, my therapist asked me, well, who are you?
I looked at him, really puzzled, and I said, “Well, who do you mean? Is it Katrine as in
when I’m with my parents, or Katrine as a friend or as a mother? I mean, which one of
them are you talking about?” He looked at me, smiled and said, “If you are just you,
who are you then?” And I said to him, “Well, she doesn’t exist.” I always take my cues
from the people around me, so when I’m with the Rolex club, I am the Rolex snob; if I
am with the alcoholics in an AA meeting, I’m the girl from the park bench. [W3]
The women articulated an experience of being no one, of being “the

one I think others want me to be. And then I am in that until I can’t handle it
anymore. And then I run like hell, because I failed at that too” [W3]. Another
participant reported a closely related experience of “primarily being what
others think”; her view of herself is “completely dependent on the person I
am currently dating” [W1], which thus varies with her frequently changing
boyfriends. When she is alone, she does not know who she is. “I need oth-
ers . . . in order to feel that I exist, because if I was all alone, I would just
be nothing” [W1]. Another participant said, “Fundamentally, I am nothing,
really, and then with other people, I can be different persons. Then at least I
am something” [W10].
Some of the participants have an experience of being unable to be genu-
inely or “personally” present in the here-and-now, unable to connect psycho-
logically or emotionally with others. This difficulty relates to their disturbed
identity and their inability to know who they are: “I am not myself, because
I don’t know who ‘myself’ is” [W14], which in some cases seems related to a
subjective experience of inauthenticity. For most of the participants, the ques-
tion “Who am I?” primarily causes confusion, as illustrated in this statement
from one of the women: “Often, I actually feel that I am me, and then I have
this feeling that ‘this isn’t me, I’m just talking, doing what I’m supposed to do’”
[W9]. A few of the participants reported that they try to anchor a sense of self
in something outside the self, such as a social group, school/academic marks,
weight, or BPD diagnosis: “A big part of me is my borderline, if that makes
sense . . . If my diagnosis were taken away from me, I think my world would
collapse, because I have built this identity . . . based on being borderline . . . so
I would be totally confused . . . because I use it as a kind of excuse, if I feel
bad or I have mood swings, ‘well that’s because I am borderline’” [W16]. As
one of the women put it after describing one of her many failed attempts to
find her own self by engaging in (short-lived) hobbies, projects, and activities:
“I’m always looking for something that might be me” [W11]. Unfortunately,
she fails again and again.
2. “FAKE IT TILL YOU MAKE IT”;

USING MASKS AND FAÇADES TO STABILIZE THE SELF
In various ways, 15 of the 16 participants mentioned putting on a mask or a
façade in an attempt to structure or stabilize themselves and “survive” in their
daily lives, for example, wearing a particular dress as a kind of “uniform” to
prop up the self or putting on a particular style of makeup, getting spectacular
tattoos, or pretending to be tough. Some of the women said they try hard to
look and act “normal,” in some cases in an attempt to be socially accepted, in
other cases mainly to hide feelings of inner vulnerability, sadness, and what
they see as bad or unacceptable parts of the self. One of the women cannot
go outside at all if her façade is not perfectly in place, due to her inner or
underlying chaos, “but if I could make everything look perfect on the outside,
it would be like, at least something is working. Then I could focus on that
instead of the mess inside” [W6]. In some cases, the alternating façades are
not only intended to stabilize the self but are also part of an effort to “find”
or construct the self: “I have had lots of different styles, it has all been part
of a hopeless effort to figure out, is this really me? Is this one working better
for me than the other one did?” [W16].
Some of the women explained how they identify with and try to play
what they perceive as accepted social roles in an effort to be socially accepted
and feel that their self is “good enough” in the (imagined) eyes of others. One
participant described always trying to be “the sweet girl,” always pretending
to be very happy and “very, very sweet to others.” Even in situations where
she is angry and feels like being or doing something completely different, “I
keep up this façade” [W12]. As described by one participant, the self may
try to hide behind a seemingly carefree and happy façade to avoid feeling
exposed: “I don’t want people to see this [unhappy, angry] side of me, they
should only see and remember the happy Anne [name changed]” [W16]. In
some cases, the façade is put on in an effort to act or look “normal.” One of
the women is completely convinced that her boyfriend wants her to be “the
innocent housewife,” and she explained how she “can take on this role, buy-
ing potted plants and baking cookies” [W1], knowing all the time that this
is not her, that she is simply playing a particular role to keep her boyfriend
happy and make him think that “she is nice.” Another participant describeed
how she “loves [her] best defense mechanisms, which are humor, irony, and
sarcasm. It works. Instead of being unsociable, I put on a façade of carefree
humor” [W3]. Others “just have to like me. Then it doesn’t matter who I am
or what I am.” All the women seemed to know that the façade is only skin-
deep, a mask used to hide what is (or is not) inside them:
I have many different façades. . . . Behind them there is chaos, not knowing who I am
or how you’re supposed to act . . . on the outside, I have no problem appearing calm, in
control and completely integrated. But inside, I am going 150 miles per hour, trying to
figure out, am I doing the right thing, am I giving the right answers? [W3]
What appears in these statements is a self that is haunted by anxiety

and a constant fear of being exposed as defective, phony, and inadequate
and, ultimately, of being rejected, should the mask slip, which it often does.
We found interesting differences in how the women talked about their
façades and the extent to which they are (or perceive that they are) in control
of the masks and façades they present to outside world. Some construct their
façade as part of a conscious attempt to control themselves and how they are
perceived by others. One participant explained how she (in retrospect) used
her pink hair and unusual hairstyle to control what others saw when they
saw or met her. At the same time, she described how “all of a sudden” (as if
it was something happening outside her control) she cut off all her hair: “I
didn’t like the way I was, and you can’t change that, but you can change how
you look” [W1]. This woman has managed to convince not just other people
but also herself that her carefully constructed façade or “how I want to be
seen by others is actually how I am” [W1]. When she is forced to realize that
others see through her façade, the façade cracks and falls apart. Several of the
participants described putting up a façade without even thinking about it, as if
it is something that happens automatically or as part of an unconscious habit:
“It happens completely unconsciously, and I catch myself thinking ‘now I’m
doing it again,’ but I can’t stop it, because I don’t know what else to do.... I
feel that I can’t do anything other than being this façade” [W6].
For some, this unconscious or involuntary inclination to put on a mask
results in feelings of self-alienation and inauthenticity:
Afterwards I feel I wasn’t really there . . . a feeling of not really being myself around my
friends. . . . It’s like, I pick up characteristics. When I see, well, someone is doing this and
it looks right, so if I do the same, it might somehow work for me too, . . . but I still get
this sense of, that’s not me, and so it doesn’t feel real at all. [W6]
In some cases, this makes the person feel like an imposter, always lying
to other people and being in the world “on autopilot” or “leading a double
life”: “I am not really ‘there,’ the way I would like to be. . . . Again, it’s just
that I just do what they do, so it doesn’t feel real” [W6].
3. PAINFUL FEELINGS OF THE SELF AS BROKEN,

DEFECTIVE, AND VULNERABLE
All the women described painful feelings of their self being broken beyond
repair, feeling deeply defective or wrong, worthless and incapable of function-
ing or acting like a normal person: “I feel like there’s a hole in the middle of
my soul that nothing can repair [or] fill” [W14]. “I am fundamentally wrong,
I don’t fit in anywhere. No matter who I’m with, I am always the odd one
out. . . . Something inside me is completely misaligned, my mind doesn’t work
like other people’s minds” [W3]. One of the women said, “I’m just a com-
pletely broken person. I am damaged, I have seen too much, experienced too
much” [W13]; she also illustrates how identity diffusion and the associated
search for meaning and sense of intensity can lead to a life on the edge. In
many of the participants, views of the self as abnormal, totally inadequate,
and fundamentally broken are accompanied by a deep fear of being rejected
or excluded from social groups and communities (see Category 4).
The perception of the self as being wrong is often related to others’ imag-
ined view of the self: “All the time I have this feeling that I’m wrong when I’m
with others . . . ; that others think I am wrong” [W12]. Consequently, some
of the women try even harder to be “good enough” and accepted by others.
One of the women, calling herself “the achievement princess,” said, “I am
never good enough, but I’m always trying, always trying to overachieve. If I
were to run a marathon, I would run 42 km, and then I would run an extra
3 km . . . to prove that I’m good enough” [W3].
In many cases, the perception of the self as being wrong and defective
also involves—and is particularly focused on—the person’s body: “I hate my
body, I always have. I can’t remember a time when I didn’t hate my body; I
am fat, I am too short, well, everything. I am not happy with any part of my
body and never have been” [W12]. One of the women said, “My greatest
wish is to be born as a man . . . , then this [body] and this [mind, soul] would
fit together. . . . I am deeply dissatisfied with my body, . . . the different parts
of my body are disconnected. . . . It’s like Lego bricks that don’t fit together,
they’re just thrown together randomly” [W13]. One of the women hates her
“body so much that I can’t handle being naked. I hate taking a shower. . . . I
can’t handle looking down and seeing myself” [W16]. In some cases, the
self-hate is directed at the person’s particular way of being a woman: “I just
imagine that all other women, well, girls and women, are much more feminine
than me” [W8]; “being a woman in the wrong way is something that I think
about a lot” [W11].
Several of the women used metaphors to describe a painful sense of their
self being deeply defective, missing essential parts, and making it impossible
for them to develop into a whole or integrated and well-functioning person:
“Hell, I am out of order, like a machine where a bolt is missing, that’s me”
[W15]. “I feel that I am basically misassembled, and the welding . . . inside my
head is botched” [W11]. “I feel like porcelain, fragile. I am cracked porcelain”
[W2]. One of the participants said, “If I were a piece of pottery, some of the
parts would just never have been there, and no one would ever be able to put it
together correctly, no matter what” [W9]. Another woman said, “No one will
ever like me, I am too defective to be here. . . . I am like a broken bucket with a
small hole in the bottom where water keeps running out, because something is
missing, . . . and I have no idea what might plug that hole” [W10]. She reflected
on how she might understand and heal her sense of the self as defective:
Something is missing [inside], it’s this feeling that if there was ‘something more,’ I would
be happy. I have often thought, if only I had a boyfriend, I would be happy, or if I did
this or that, then I would be happy. Well, I’ve tried these things but had to realize that,
no, that wasn’t it either. [W10]
Finally, several of the women mentioned feeling like a jigsaw puzzle

with one or more pieces missing or with empty spaces where the remaining
pieces do not fit in. All of these are metaphors for being incomplete or lacking
essential parts that they need to feel like a whole person, a person with a fully
developed and coherent identity.
4. FEELING THAT THE SELF DOES NOT FIT IN;

THE SELF IS NOT EXPERIENCED AS AN INTEGRATED
PART OF SOCIAL COMMUNITIES
All the participants except one reported feelings of being misplaced, left out,
or marginalized and unable to be an integrated part of social groups and
communities, often related to alienating feelings of being different from “all
the others” in negative ways. It is a feeling of being “the lone rider,” “the lone
wolf,” “out of place,” or always having been “the black sheep of the family”:
“I will always feel that I don’t fit in, that my being here is wrong. . . . I am not
part of the group, I am the one driving in the emergency lane that has not
been able to ‘figure it out’ [how to be normal and belong]” [W3]. As one of
the participants put it, “I feel completely isolated. . . . I feel that I am never a
part of the group” [W3]. Another participant articulated her experience as
follows: “I don’t fit in AT ALL! . . . I don’t feel comfortable anywhere. The
only place I feel good is on the highway [alone in her car]” [W13]. One of
the women keeps asking herself: “Am I just on the sideline? Does it make any
difference whether I’m here with you or not? I feel invisible; . . . would it mean
anything if I wasn’t here, would you even notice? Are you just talking to me
out of pity?” [W10]. Another participant conveyed her painful experience in
social settings: “No matter where I am, I always feel like I’m at a dinner party
where everybody is talking about something, and I have no idea what the joke
is all about, . . . just being unable to participate, to be a part of it” [W15]. The
women’s experience of not being included in social communities thus relates
both to unspecific feelings of the self as being insufficient and to feelings of
not really knowing how to be and behave in order to belong. These feelings
are related to images of the self as defective (see Category 3).
These feelings of being out of place, isolated, or excluded from social
communities are often intensified when the participants imagine how every-
body else (allegedly) is perfectly integrated and socially accepted in all kinds
of communities—communities that the affected person is excluded from. It is
a feeling “that they [all the others] have something I don’t” [W1]; imagining
that others share something that the person is not a part of and never will be:
“I know that people share something, they do things together and have some
kind of connection, . . . while I have always felt I was on the outside of all that”
[W6]. One of the women said, “I always feel left out. . . . I am the one that’s
on the outside, I will never feel that I am inside, part of something, . . . there is
something about me which means that I will never be part of it [the group]. I
will always struggle, trying to be accepted. But it will never ever be enough”
[W15]. In some cases, the women related their feelings of social exclusion to
what they see as the social or psychological deficits of their self: “I’m unable
to talk about myself, except with my therapist. If somebody asks me how I
feel, what should I answer? I don’t know what to say to people. I don’t know,
I fucking don’t know what to say” [W15]. Some of the women explained
that they have developed an ability to (appear to) adapt to various social
settings by mimicking others and trying to be and do like them, but at the
same time feeling they are “not really there,” just playing an adapted social
role. And when the attempt fails, they back out: “I try to be a part of it, but
very quickly I give up, . . . and then I withdraw” [W12]. Others are so afraid
of being excluded or left out that they actively avoid becoming part of social
communities in the first place: “I have always been the lone wolf—in school,
in high school, at the university. It’s the exact same role that I play. It’s a role
that I choose . . . in order to avoid feeling sad and being rejected” [W15].
5. INNER EMPTINESS, EXTENSIVE FEELINGS OF

MEANINGLESSNESS AND LONELINESS
Intimately related to the perceived inability to answer the fundamental identity
question—“Who am I?”—all the women reported a painful and alienating
feeling of inner emptiness and meaninglessness, in most cases both when
they are alone and when they are in the company of others. Eleven of them
reported this explicitly, while the remaining five did so more implicitly and
had some difficulty verbalizing their experiences of inner emptiness and feel-
ings of being disconnected, even in the presence of others: “It’s difficult for
me to feel the emptiness because all the time I’m trying so dammed hard to
make it disappear” [W7]. They would all like to escape these feelings of inner
emptiness and loneliness, calling them “really scary,” “uncanny,” and giving
rise to an overwhelming fear of nothingness.
Most of the women associated their sense of “not knowing who you are,”
perceived inner emptiness, and profound feelings of meaninglessness and indif-
ference: “This feeling of not knowing who you are, you know, of just being
here without having any inner substance” [W11]. “I feel like I’m living in a
glass bubble that is getting smaller and smaller and smaller and smaller. I am
breathing, the glass is steaming up, and I can’t see what’s going on outside.
I can’t see where I’m going, I can’t see anything—and it’s like being empty.
Because there is nothing, and there is just nothing that makes any sense at
all” [W13]. One of the participants described her sense of self as follows: “I
feel that I’m just an empty shell, walking around. . . . I’m not happy, I’m not
sad, I’m nothing. I am just here, an empty space, in a black hole, . . . there is
nothing. It’s really, really painful . . . and I’m scared, thinking, will I never feel
anything again? . . . I get into this zombie state, . . . just sitting there, staring
into a black void” [W16]. Another woman said that feeling empty inside “is
the most familiar feeling in the world to me. It’s an empty hole, a hole in my
stomach, . . . it’s like my basic emotion” [W5]. In addition to feelings of inner
emptiness, some of the women experience a profound and pervasive sense of
meaninglessness, illustrated in this quote from one of the participants: “There
ought to be a better reason for my being in world than just having borderline,
going to group therapy, and trying to ‘get better.’ When I get old, I’m going to
die anyway. It all seems so empty, so pointless” [W5]. Several women spoke
about intense feelings of boredom or fears of appearing boring to others, also
related to feelings of inner emptiness.
All the participants felt lonely, also in the presence of others, even sig-
nificant others. “I feel like I am inside a bubble, . . . that there is this distance
between me and other people. . . . I feel all alone in the world, even when I am
with others; . . . deep inside, I feel alone among all these people that I spend
my time with” [W8]; “I am always alone, even when I’m with a thousand
people. . . . I don’t let anyone get close to me” [W3]. In some cases, perceived
meaninglessness and feelings of personal insignificance are closely related: “I
feel completely insignificant when I am with others, . . . that I have nothing to
say—and I keep asking myself, why am I here, what use am I?” [W5]. One of
the participants related her loneliness to her need to keep others at a distance
and being unable to be “herself” in relationships: “It can be a very lonely feel-
ing, this constant need to check these barriers and accommodate others—and
never really feeling accepted. That makes me feel even more lonely than when
I’m just alone, because you realize that you’re unable to relax and be yourself
[in the presence of others]” [W10].
Some of the women also articulated feelings of wasting their time, doing
things that do not make any sense to them. One of them said, “I feel I’m
wasting my life. . . . I just try to fill up my life with things that make sense,
because nothing in my life really makes any sense. . . . this sense of everything
being meaningless” [W9]. Another participant articulated a “feeling that I am
wasting my time, like everything is just going in circles and I begin to worry
that time is just running out, and all the things I haven’t accomplished, and
all the times I have just gone round and round in circles and started over
again” [W6]. Finally, approximately half of the women described desperately
trying to handle or escape these painful feelings of emptiness and loneliness
by taking drugs, drinking excessively, cutting or engaging in other kinds off
self-destructive behavior, binge watching TV series, excessive physical exer-
cise, or being constantly on the move: “I am just empty. . . . I get into my car
and drive, drive, drive, listening to music, just to feel something” [W13]. This
woman has crashed her car several times.
6. “I DON’T KNOW WHAT I WANT”;

LACKING IN AGENCY, CONCEPTIONS OF
OWN FUTURE, AND ABILITY TO MAKE DECISIONS
Identity diffusion is often manifested in feelings of not really knowing what
one wants, an inability to make choices (lacking in agency), and confusion
concerning one’s own basic norms, values, and internal or “personal” criteria
for what is good and bad and what one likes and does not like. These problems
are intimately interrelated in the sense that deficits in one’s inner horizon of sig-
nificance mean a lack of access to stable inner criteria for making choices and
difficulty sticking to one’s choices. As articulated by one of the participants:
“I can’t figure out what I want. When I am alone, I feel completely unable to
make decisions” [W12]. Similarly, one of the other women said, “When I have
to make decisions concerning what’s right, what’s important in a situation
like this, I have so many doubts, and everything gets mixed up. I can’t make
up my mind, and usually I end up asking somebody else ‘what do you think
is best, what should I choose?’ Because I can’t do it myself; . . . nothing seems
more important to me than anything else” [W6]. All the participants but one
described closely related experiences and challenges: “It’s very confusing not
to have this unifying thread or principle in your life, like who am I, and what
do I want. It makes it very difficult to make plans” [W10].
One way or another, all the women have a hard time thinking about their
own future. Some of them talked about being very spontaneous—one could
also see this as being impulsive, often in potentially self-destructive ways,
dictated by the heat of the moment:
Where do I see myself in 5 years? I don’t see myself anywhere, I’m just trying to live
in the moment. Because I still haven’t decided whether I’m going to be here tomorrow
[or take my own life], but I am here today. . . . I don’t have any long-term plans. I know
what I can handle today, I don’t know what I will be able to do tomorrow. I know that
I didn’t sleep last night, so today is going to be a long and tough slog. Maybe I’ll sleep
tonight, then I will have a terrific day tomorrow. Long-term plans, no thanks, . . . that
way I won’t be disappointed. [W3]
Most of the participants feel unable to determine what is important to

them, what they want, what they like, and what their plans for the future
are. One participant said of her lack of a future perspective, “I don’t see any
future at all. Where will I end . . . I can’t imagine. I have had this feeling that
if I tried to look forward, I just couldn’t see myself anywhere. Like tomorrow
is just a fog. I don’t know what’s going to happen or where I stand, it’s all
very uncertain” [W3].
The lack of any stable ideas about what they want makes it difficult
to plan ahead. One of the women explained why she does not look to the
future: “I am very spontaneous. Now I want this, then I want that, and
suddenly I get this third idea. I want everything . . . it’s all very much like
this [abruptly, unexpectedly]. Then it might disappear and be replaced by
something else. So it’s hard for me to figure out what I want” [W12]. Many
of the women associate thinking about the future with fears of being disap-
pointed: “I don’t like to think about it [the future]. I don’t want to have any
hopes or expectations because that leaves you open to disappointment. So I
just try not to think about what I would like to have happen in the future”
[W1]. One of the women talked about her failed attempts to take control
of her life: “Sometimes I try to have something like [long-term goals], like,
now I will do yoga every day for some time, or I won’t drink too much
for a month, beginning today, but I’m never able to stick to those kinds of
goals. Never. . . . I can’t handle doing anything other than what I feel like
doing today” [W1]. Because of her fragile identity, her goals keep changing
unexpectedly and are outside her control, and she is unable to be persistent
in pursuing longer term goals.
Constantly changing self-states or conceptions of “who I am” and “what
I want” undermine personal agency: “When I finally feel that I have reached
a point where I know [what I want], then it changes again” [W6]. “I don’t
trust my own judgment. Do I actually have any judgment, or is that broken
too? That [kind of doubt] affects every aspect of my life” [W11]. Several
participants talked about how things “just happen” in their lives; they do
not know why; they feel unable to predict what will happen tomorrow, and
they are not in control of their own lives and personal future. “I would like
to make plans for how things should be, but I am not the captain on my own
bridge [W13]”; “It’s hard for me to act, because I don’t know what’s going to
happen, and I don’t trust myself” [W7]. A few of the women described how
they end up feeling paralyzed, unable to make competent decisions and act:
“Often I end up doing nothing. It just gets overwhelming” [W12]; “When it
comes to making decisions, I feel paralyzed . . . everything, like, disappears,
everything ‘I am’ disappears. . . . I kind of forget what’s important to me and
what it really is that I want. . . . I can’t control it [my life], things just happen,
because I don’t have the motivation and the willpower to take control of my
life” [W11]. This inability to make even trivial decisions also affects their daily
life: “What I find important and give priority keeps changing. It’s really hard
for me to make decisions; when I’m shopping, it can take me 20 minutes to
decide if I should buy orange juice or something. Or I might put some stuff
in my basket to make dinner and then second-guess myself, like, no, I don’t
want that after all” [W8].
7. IMMENSE NEED FOR CONTACT, ATTENTION,

AND RECOGNITION FROM OTHERS TO STABILIZE IDENTITY
Almost all the participating women spoke of a great, in some cases almost
overpowering, need for attention, affirmation, and recognition from others:
“I’m a junky for affirmation, being recognized as okay, as good enough and
deserving of living on Planet Earth” [W3]; “Others are like a drug to me,”
and being alone is “like hell” [W13]; “I need him [boyfriend] to confirm, over
and over again, that he is not leaving me . . . all the time, I need to be assured
that people around me find that I am sweet and nice to them” [W12]. As one
of the women put it, “I have a tremendous need to be seen by others, every
minute of the day” [W1]. There is a constant need for affirmation that is often
related to “not knowing who I am”: “I constantly need others to affirm who
and how I am, because I have such a hard time figuring it out on my own”
[W16]. When alone, they often become destabilized. One participant described
what typically happens whenever she is alone:
I get extremely restless, not what I would consider a normal kind of restlessness, I also
get hyper-emotional, like very angry or very sad, and all of a sudden I feel extremely
happy and I begin to sing and dance, I feel like pounding the walls, because I am so
unsettled inside—especially if no one has time to meet up, and I write everyone, asking
if they could meet, and they can’t. [W5]
In some of the women, this need for attention and reassurance of an

unstable and highly vulnerable self is particularly pronounced when they feel
abandoned by significant others, and the self is, presumably, destabilized. One
woman said that when she feels abandoned by her boyfriend, “I get really
scared and I get this huge need for attention and attendance. . . . He has to
tell me 50 times that he really loves me; I need to be cared for, almost like a
helpless little baby” [W1]. Most of the women need others just to get some
(fragile) sense of meaning in their lives—a sense of meaning that collapses
when they feel abandoned: “When he has abandoned me, I have absolutely
no idea what I can do, I feel that absolutely nothing in my life makes any
sense, everything seems deprived of meaning. I have nothing” [W8]. They are
unable to enjoy being alone but need others to provide meaning and security:
“I never get this feeling, that I have heard others have, of just being able to
relax and enjoying being on your own . . . just being able to relax in your
own company. I never get that feeling” [W6]. This experience is presumably
related to a diffuse sense of identity and related feelings of inner emptiness.
Due to this strong need for affirmation, some of the women are constantly
trying to live up to how they imagine others want them to be, act, and behave.
Many of the participants described how they renounce their own needs and
personal boundaries, trying to ensure the needed affirmation and recognition.
They will do everything they can to satisfy others in order to ensure that they
are liked and will not be abandoned: “I suspend everything inside me, all
my own needs and feelings. I change my entire life to make others happy, no
matter what I feel inside” [W3]. One of the women said, “I have done a lot
of things that, well, I didn’t like to do, but I just wanted people to like me”
[W8]. She also articulated what might be the psychological background of
this self-effacing behavior: “I didn’t know who the hell I was, when I was on
my own”; and when she is alone, “I feel, like, indifference or not knowing if
anyone at all cares about me” [W8]. Similarly, another participant said, “If I
am not in an interaction with others, I am just empty and all alone, so why
be here at all. And that’s a dangerous place to be, . . . then I might as well kill
myself” [W3]. Inner emptiness and extremely low self-worth, related to identity
diffusion, thus make the women renounce personal needs, boundaries, and,
in some cases, personal safety.
Implicitly or explicitly, many of the women described how they depend
on others to stabilize the self or a rudimentary sense of “who they are,” and
keep themselves afloat:
I get so dependent on other people; I don’t know what I think or feel. I just do what they
do, then I can’t be wrong. . . . My thoughts are like his [boyfriend], my feelings are like
his, and my views are the same as his. . . . If I copy him and what he does, I feel safe, I
can’t be wrong and he has no reason to leave me. [W14]
This self-effacing behavior may exacerbate the feeling of “not knowing

who you are”: “I become extremely clingy, you know, it’s like my whole
sense of existence is so, so unstable. So when I begin to depend on another
human being, that person becomes my entire existence. . . . I live through
this other person, and when that person is not there with me, I am gone, I
don’t exist” [W11].
8. FEELING UNABLE TO HANDLE INTERPERSONAL

RELATIONSHIPS; BOTH FEAR OF BEING DEPENDENT AND
OF BEING LEFT ALONE, TRAPPED IN A RELATIONAL PARADOX
All the participating BPD patients find it hard to handle interpersonal relation-
ships and being in close emotional and intimate contact with others. On the
one hand, they feel a need for interpersonal relationships to stabilize their iden-
tity (see above). On the other hand, being in these interpersonal relationships
often aggravates the perceived destabilization of self and identity; they begin
to worry, “Am I good enough?” “Am I making myself vulnerable?” “Will I be
abandoned?” They are trapped in what could be called a relational paradox:
They feel a strong need to be in a relationship while at the same time finding
it overwhelmingly difficult to handle being in one. The participants described
how hard it is for them to be with others: “I can never relax around other
people. . . . I find it exhausting to be with others” [W12]; “I feel invaded by
others; sometimes I feel like they are walking right into me, as if the lock on
my front door doesn’t work” [W4].
This inability to be in close contact with others often results in severe
ruminations (or hypermentalizing) about imagined mistakes and inadequa-
cies in interactions with others: “Turning off the brain and just being with
other people, that’s very difficult. . . . I always begin to overanalyze, which
makes me feel even more disconnected, obsessing about what to say” [W10].
One woman said, “I overanalyze everything, people’s reactions to what I say,
always concluding that they don’t like me, . . . which makes it impossible for
me to deal with that interaction” [W6]. Several participants articulated how
it feels to be captured in a relational paradox: “I can’t handle being around
other people, but I can’t handle being on my own either” [W16]; “When I’m
with someone, I often get this feeling that, argh, I need to go home and be
alone with myself. But then, when I get home and am on my own, I am over-
whelmed by this urge to call everybody and talk to someone” [W8]. One of
the women described her experience of the relational paradox: “I just need
to be alone, . . . but when I’m alone I get so depressed. . . . I have absolutely
no idea, why I am having these feelings” [W8].
The perceived relationship paradox often leads to broken relations. One
of the women talked about her ambivalence and inability to control her urge
to move into and out of near symbiotic relationships: “I am used to symbi-
otic relationships. . . . If I can’t have a symbiotic relationship, it’s almost as
if I’m not interested. But as soon as the symbiosis is established, my urge
for freedom and independence is triggered, and I need to get away. I swing
like a pendulum between symbiosis and freedom” [W4]. Another participant
articulated a possible intimate connection between the relational paradox
and identity diffusion:
It’s highly ambivalent, I want to fuse with the other person, because that would make
me feel that I exist. But I also have a fear that when I only exist through you, and we
fuse into one, it would be a disaster to lose you, because losing you would mean losing
myself. Somehow, it’s all linked to this fear of being abandoned, which is also a fear of
non-existence. I am afraid of abandonment, because in my head, that means that I will
no longer exist; I am afraid of losing myself. [W11]
She continued, “On the one hand, I really need time alone, to recuperate—
because it’s so hard for me to socialize. On the other hand, when I’m alone,
I don’t know who I am, and I get so restless.”
9. USING SEX TO DISTRACT THE SELF AND REGULATE PAINFUL

SELF-STATES; PAINFUL CONFUSION AROUND SEXUAL NEEDS
One of the participants described what she perceives as a healthy sex life. In
her experience, sex is an area where she “can’t fail.” The other 15 women
experience various sexual problems, many of them related to their vulnerable
self and brittle identity. One seems to experience sex almost like a sanctuary in
her life: “It’s one of the few moments in my life when I don’t think of anything
else than what is happening right now” [W7]—while at the same time being
almost overwhelmed by what she sees as her strong sexual needs. Almost all
the women have used sex as a way of gaining acceptance and recognition
from others or avoiding abandonment: “Most of my life I have used sex as
a way to be accepted and recognized as good enough, primarily in one-night
stands where having sex made the other person happy. . . . Personally, I could
easily do without it” [W16]; “Sex is a way for me to be affirmed as being good
enough” [W12]. Others have used sex as a distraction, “a means of handling
[emotional] problems” [W10]. One of the women contemplated what she is
looking for in sex: “I don’t know what I’m looking for. Maybe I’m looking
for some artificial form of care, love, tenderness, I don’t know. . . . I think
attention is what I’m looking for” [W3]. She does not feel any sexual desire.
Approximately half of the participants seem to have completely split off
their sexual life. They are confused about their own sexual needs and bound-
aries, and some of them are wondering whether they are asexual: “Now, I’m
actually beginning to wonder if I may be asexual. . . . Sex is something that
is being done to you, more than something you do to others” [W1]. Some of
the women primarily associate having sex with masturbating in solitude, in
some cases in ways that seem to indicate that they masturbate in an attempt to
regulate their self: “When I’m alone, I feel like having sex with myself. . . . As
soon as my boyfriend is out, I feel a need to have sex with myself” [W12]. In
various ways, almost all the participants reported feeling unable to be emo-
tionally present and enjoy having sex with another person: “Almost every
time I have sex, I feel like, when is this over?” [W1]; “For me, sex is really just
something to get over with. It has been like that most of my life, really, . . . and
I never have what you could call an orgasm” [W16].
Deep-seated confusion concerning “who I am” seems to affect the core
of the women’s sex life and identity. It also manifests in severe confusion
around some of the women’s sexual orientation and needs: “I can’t figure out
what kind of sex I like” [W1]. One of the women explained how she can-
not allow herself to wonder whether she might be homosexual or bisexual,
“because I’d never be able to figure it out. I get scared about who I would be
then, if . . . it’s like a battle inside my head, without a real conclusion” [W6].
Another participant said, “I don’t care if I fuck two men or two women, I’m
indifferent, couldn’t care less, I don’t feel anything anyway. . . . I just need to
be the object of someone’s desire, if it’s a man, a woman, a gay couple, or
whatever, someone who’s 60 or 20, I couldn’t care less. . . . My needs aren’t

real, they are not worthy” [W3].
More than half of the women said that they need to keep sex and feel-
ings separate or that they are unable to integrate having sex with someone
and being emotionally involved with him or her: “I keep sex and feelings
separate. I am like a man, sex is sex, and feelings are something completely
different” [W3]; “My emotional life and my sexual life are completely discon-
nected, I wish they were more connected, . . . and I know this is a symptom
of some of the other problems I have. . . . When it comes to having sex, my
feelings are shut down somehow” [W10]. One of the women said that she
is completely uninvolved emotionally when she is having sex, and that she
associates emotional involvement with danger: “I don’t care, I’m completely
indifferent, I feel nothing, . . . it’s just trivial, I have no feelings. . . . I could end
up in an emotional pinch, I could begin to have feelings because he shows me
something I need emotionally, . . . and that’s dangerous” [W3].
DISCUSSION
The data reported in this study offer nuanced descriptions of how essential
aspects of borderline personality disorder, namely, aspects related to identity
diffusion, are manifested in the subjective experience of adult women diag-
nosed with BPD. The main objective was to collect nuanced descriptions on
how identity diffusion is manifested in the subjective experience and daily lives
of people diagnosed with BPD—the phenomenology of identity diffusion—not
to develop new theoretical or statistically derived (sub-)categories of identity
diffusion nor to focus on structural, dynamic, etiological or (neuro-)cognitive
aspects of BPD and identity diffusion. The participating women’s nuanced
and highly interesting descriptions of their subjective experience associated
with identity diffusion disconfirm the predominant notion that BPD patients
generally lack the self-insight and psychological-mindedness necessary for
being able to provide valid information about complex aspects of their inner
psychic life and identity diffusion.
Nine categories of manifestations of identity diffusion emerged from
the interpretative phenomenological analyses of our collected data. With
very few exceptions, all of the participating BPD patients reported subjective
experiences classified in all nine categories—experiences related to identity
diffusion. Our data illustrate how the ability to answer fundamental ques-
tions related to human identity (“Who am I?”) is severely and painfully com-
promised in patients with identity diffusion (Category 1). The participants
articulated that they are having a very difficult time reconciling contradic-
tory self-representations to form a stable and coherent identity (Category 1),
how their self-image continuously fluctuates, and how their self-concept and
behavior are dictated by momentary emotions or mental states and by efforts
to please imagined expectations from others (Category 2). Most of the women
with BPD have an alienating feeling of inner emptiness (Category 5), often
accompanied by associated feelings of being invisible or totally insignificant
in the eyes of others—“if I were not here, what difference would it make”—in
addition to feelings of social marginalization and lack of belonging (Category

4). Most of the women articulated how they play social roles, put on masks,
or put up façades in an effort to stabilize the self and hide painful feelings of
vulnerability, inner chaos, sadness, and socially unacceptable mental states
(Category 2). They also use these façades in an attempt to “find” or construct
the self and figure out “who they really are.”
Patients’ descriptions of not knowing who one is and trying to com-
pensate or cope by putting up a façade are associated with what Deutsch
(1942/1965) called the “as-if personality”: “a highly plastic readiness to pick
up signals from the outer world and to mold oneself and one’s behavior accord-
ingly” (p. 265). As formulated by two of the women in our study: “If I can’t
figure out what I want, I can do what others do” [W6] (Category 2); “I just take
color from my surroundings and the people I am with” [W14]. Outwardly, a
person with an as-if personality may seem normal, but she will have an air of
inauthenticity, giving the impression that her “whole relationship to life has
something about it which is lacking in genuineness and yet outwardly runs
along ‘as if’ it were complete” (p. 263). Deutsch interpreted this use of masks
and façades as an attempt “to give content and reality to their inner empti-
ness and establish the validity of their existence” (p. 266). This interpretation
matches how the women in our study end up feeling inauthentic, “not really
there” in interactions with others.
Most participants showed signs of deficits in agency or in the ability to
function as autonomous individuals, signs related to the absence of a stable
inner horizon of significance, and the absence of stable inner goals, norms,
and values associated with a mature identity (Category 6). As argued by the
Canadian philosopher Charles Taylor (1991, p. 35), when we define who we
are and make choices in our daily life, “we have to take as background some
sense of what is significant,” what is important to us—grounded in a pre-
existing and stable (internalized) horizon of significance, not just momentary
feelings, impulses, or pure subjectivism. Making choices is only possible and
meaningful when one is convinced that “some issues are more significant
than others” (Taylor, 1991 p. 39). Similarly, we can define our identity “only
against the background of things that matter” (Taylor, 1991, p. 40). Several
of the participants showed signs of not having internalized or established this
stable and authoritative inner sense of significance where some issues are more
important than others (Category 6); this makes it difficult for them to make
decisions and navigate competently in the world.
Moreover, our data illustrate how identity diffusion is closely related to
other defining characteristics of BPD, such as inner emptiness, fears of aban-
donment, temporal discontinuity, inability to handle intimate relationships,
and painful feelings of loneliness, meaninglessness, and conceptions of the self
as deeply defective and worthless (Categories 3 and 5). Obviously, it could be
argued that some of the presented subjective experiences are more associated
with (or caused by) impulsivity, mentalization deficits, or reduced ability to
handle interpersonal contact than with identity diffusion. In our view, this is
not an either/or issue but is a reflection of the complexity and multicausality
of identity diffusion and other defining characteristics of BPD, with identity
diffusion and deficits in self-regulation (impulse control) and mentalizing as

intimately related problem areas.
Most of the women described feeling trapped in what we have called
a relational paradox: having a huge need for contact and recognition from
others to stabilize a brittle identity—to feel they exist and have some form of
identity (Category 7)—while at the same time feeling incapable of handling
interpersonal relationships due to fears of aggravating the perceived conse-
quences of identity diffusion, feeling evaded or threatened by annihilation
(“losing oneself”) in intimate and emotionally overwhelming contact with
others (Category 8). Most of them cannot handle being on their own but
also struggle being around others, as they tend to hypermentalize and conse-
quently have to withdraw to protect the highly vulnerable self (Category 4).
On the behavioral level, this relational paradox is associated with disorganized
attachment, which is characterized by the absence of a coherent strategy for
interacting with significant others and rapid oscillations between approach
and withdrawal behaviors (Beeney et al., 2017, p. 207).
The present study shows how features of identity diffusion suggested
by Akhtar (1984) manifest themselves in the daily life of people with BPD,
including severe temporal discontinuity in the subjective experience of self
(Category 1), inauthenticity (Category 2), and prolonged fluctuations in behav-
ior, painful feelings of inner emptiness (Category 5), and confusion regarding
essential questions related to personal values, long-term goals (Category 6),
sex life (Category 9), and so forth. Generally, the women’s reported subjec-
tive experiences support and enlarge established conceptions of identity dif-
fusion as formulated by Kernberg (1984, 2016), Akhtar (1984), and others
(Yeomans et al., 2015). Our data are also in line with the factors of identity
diffusion presented by Wilkinson-Ryan and Westen (2000) and contribute to
a deeper understanding of these aspects of identity diffusion, in particular the
two essential factors of “subjective self-incoherence” and “inconsistencies in
thoughts, feelings, and behavior.” In addition, one could argue that the reported
data support the idea of a temporal splitting of the self, as suggested by Fuchs
(2007). They also contribute to a deeper and more nuanced understanding of
identity diffusion, with the potential to improve psychotherapeutic treatment
of individuals with personality disorders by focusing on severe disturbances
in identity.
Finally, the reported data on sexual challenges experienced by the par-
ticipating women support Kernberg’s (1984) theoretically derived idea that
identity diffusion will make it difficult to integrate sex and love. Several of the
participants reported using sex as an instrument for emotional self-regulation
and a need to split sex and emotional involvement, a reality accompanied by
feelings of loss and sadness in some of the women (Category 9). BPD and
identity diffusion affect the sex life and ability to enjoy sex for almost all the
participants. Most of them use sex as a way to be accepted and recognized
as being good enough, to distract themselves, and to cope with emotional
problems (Category 9). The extent to which BPD and identity diffusion affect
the person’s sex life and cause sexual problems is most likely underestimated
in the literature (see Dulz et al., 2009) and is a highly relevant theme for
future studies. The findings from this study expand our understanding of
the inner subjective lives of people with BPD and thus broaden the founda-
tion for effective psychotherapeutic treatment of individuals with personality
disorders. As argued by Kierkegaard (1859/1991) “if one is truly to succeed
in leading a person to a specific place, one must first and foremost take care
to find him where he is and begin there. This is the secret in the entire art of
helping” (p. 96). The findings from our study help us to accomplish this; they
help us to understand how it is—and how painful it is—to have to live with
identity diffusion.
STRENGTHS AND LIMITATIONS

Like all other qualitative studies, this study may be criticized for its unknown
generalizability due to a relatively small sample size. In addition, interview
data were analyzed by the first author alone, not by a larger group of quali-
tative researchers. On the other hand, all analyses were strictly structured in
accordance with the IPA approach (Smith et al., 2009), and the use of in-depth
qualitative interviews allowed us to generate subtle and nuanced descriptions
of the lived subjective experience in patients with severe identity diffusion. This
produced descriptions that are highly relevant for clinical practice and for the
clinician’s ability to understand and empathize with the subjective experience
and inner life of the individual BPD patient. As our study shows, the use of
qualitative interviews also allows us to illustrate the variation in the manifes-
tations and subjective experience of specific aspects of identity diffusion in
different individuals. We need to refrain from idolizing quantitative methods
in general and use the methods best suited to the specific research question at
hand (Levitt et al., 2017, p. 6). In this case, the use of qualitative interviews
with BPD patients served to enhance our understanding of the phenomenol-
ogy of identity diffusion in people with this disorder.
Given the transient nature of identity in people with BPD and the general
difficulties in verbalizing elements of identity, particularly in BPD patients with
a fragile ability to mentalize, one could argue that single-patient interviews are
insufficient for capturing the essential elements of identity diffusion. More-
over, the extracted themes and experiences were inevitably influenced by the
questions we asked, and one could argue that we found only what we were
looking for, in the sense that some of the questions in our interview guide
focus on well-known aspects of BPD, and that what we present is not specific
manifestations of identity diffusion but primarily subjective expressions of
BPD in general. On the other hand, the patient interviews have given us a
highly interesting insight into the subtleties of the manifestations of identity
disturbance in the subjective experience of individual BPD patients. Rather
than testing clinicians’ implicit or explicit assumptions about identity diffusion,
we primarily explored how identity diffusion is experienced and verbalized by
the BPD patients themselves. We do not claim that the presented descriptions
of how identity diffusion is manifested in the lives of women with BPD are
exhaustive, nor that the nine presented categories of possible manifestations of
identity diffusion are definitive. It could also be argued that because we only
interviewed patients with BPD and did not compare their experiences with
those of patients with other personality disorders, adults in more incidental

identity crises, or normal controls, we cannot determine to what extent the
presented manifestations of identity diffusion are specific to patients with
BPD. This is an interesting question for future studies.
One could argue that the questions and dialogue in the interviews we
conducted have stimulated self-images and narratives about the participants’
selves and identities—narratives addressed to the interviewer and colored
not just by the interviewer’s questions but also by his personal qualities,
relational abilities, gender, social status, countertransference, and so forth.
In that respect, what manifested itself in the interviews is intersubjective, co-
constructed narrative identities and manifestations of identity diffusion. One
could also argue that the relevant objects of analysis are not just the content
of what the women are telling the interviewer but also how the participants’
identity diffusion shows itself in vivo, “live” in the here-and-now interview
situation and in the interaction and conversation between the interviewer
and the interviewees. Seen from this perspective, it could have been interest-
ing and highly relevant to include conversational analysis (Peräkylä, 2013;
Potter & Edwards, 2013) to examine the participants’ contributions beyond
their intended (conscious) meaning, with a focus on how identity diffusion is
expressed in speech patterns, dialogue, and the interactional process between
the interviewer and the participating women.
Finally, we have not addressed possible cross-cultural applications of the
presented manifestations of identity diffusion nor how sociocultural processes
might influence the development and manifestation of identity disturbance.
Historical and sociocultural aspects of identity and identity diffusion thus
merit further investigation (see Jørgensen, 2006, 2020). On the other hand,
to our knowledge, this is one of the first studies, based on in-depth qualitative
interviews, to present nuanced and detailed data on how identity diffusion is
manifested in the subjective experience, inner world, and behavioral problems
of young women living in a modern Western society and diagnosed with BPD.
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How Does It Feel To Have A Disturbed Ide

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Journal of Personality Disorders, 36(1), 40–69, 2022

© 2022 The Guilford Press

HOW DOES IT FEEL TO HAVE A

Identity diffusion is one of the defining characteristics of borderline

Keywords: identity disturbance, borderline personality disorder,

Borderline personality disorder (BPD) is a complex psychiatric condition with

Theoretically, a high level of identity integration is an essential aspect of psy-

communities am I part of and identified with?” (Jørgensen, 2018, p. 107).

Kernberg (1984) defined identity diffusion as the result of disordered and

Given the central nature of identity disturbance in BPD, empirical research

et al., 2013), and (fairly primitive) self-report measures of identity diffusion

THE CURRENT STUDY

TABLE 1. Questions From the Interview Guide

In terms of the more descriptive characteristics of the participants, only 12 of

1. “I DON’T KNOW WHO I AM”;

TABLE 2. Frequency of Recurrent Themes/Subjectively Perceived Problem Areas

The women articulated an experience of being no one, of being “the

2. “FAKE IT TILL YOU MAKE IT”;

What appears in these statements is a self that is haunted by anxiety

3. PAINFUL FEELINGS OF THE SELF AS BROKEN,

Finally, several of the women mentioned feeling like a jigsaw puzzle

4. FEELING THAT THE SELF DOES NOT FIT IN;

5. INNER EMPTINESS, EXTENSIVE FEELINGS OF

6. “I DON’T KNOW WHAT I WANT”;

Most of the participants feel unable to determine what is important to

7. IMMENSE NEED FOR CONTACT, ATTENTION,

In some of the women, this need for attention and reassurance of an

This self-effacing behavior may exacerbate the feeling of “not knowing

8. FEELING UNABLE TO HANDLE INTERPERSONAL

9. USING SEX TO DISTRACT THE SELF AND REGULATE PAINFUL

whatever, someone who’s 60 or 20, I couldn’t care less. . . . My needs aren’t

addition to feelings of social marginalization and lack of belonging (Category

diffusion and deficits in self-regulation (impulse control) and mentalizing as

STRENGTHS AND LIMITATIONS

those of patients with other personality disorders, adults in more incidental

borderline personality disorder and bipolar Jørgensen, C. R. (2008). Identitet: Psykologiske og

nonclinical sample. Psychological Assess- Peräkylä, A. (2013). Conversation analysis in psy-

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