Borderline Personality Disorder and Trauma

Trauma is sensory, visceral and cellular. It impacts our worldly beliefs, our unique place in it and is a soul wound that can shift our very core. We experience trauma with each and every one of our senses alongside our so called sixth sense, intuition. Extreme responses to trauma may include streaming tears, weeping and wailing. Also, gut wrenching, chest pain, and the overwhelming turmoil of visual images, sounds and smells flooding our brains. In order to understand trauma responses it is essential to appreciate that we are holistic beings and experience life through every cell of our mind, body and spirit. The healing of trauma is not possible by the means of “talking through it”. This must happen by “feeling through it”. E.g. fight, flight, freeze cycle.

Our bodies record everything that we experience throughout the whole of our lives translating each event to store in our mind and memory through the medium of our senses. As individuals who carry trauma, we each have our own experiences that remind us of the event.

The DSM -1V classification defines Borderline Personality Disorder (BPD) as a ‘pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity’. Presentation of the disorder typically involves a history of chaotic interpersonal relationships, unstable mood and self-image disturbances, self-injurious behaviours and other maladaptive coping behaviours (Antai-Otong 2003). It has been said that the extent of disability associated with the disorder ‘involves a terrible way to experience life’ (Gunderson 2001:13). Symptoms of BPD include significant emotional distress and impaired interpersonal and occupational functioning (Zanarini et al. 1998).  Also, to be diagnosed, a person must have at least five of the identified symptoms which are grouped into three clusters according to the DSM –IV (APA 2013) Classification.

There is some divergence between ICD-10 World Health Organisation WHO (1992) and DSM-IV (APA 2013) as to whether BPD can be diagnosed in adolescence younger than eighteen years of age.  The ICD-10 (WHO1992) sets out a criteria and classifies overall groups of disorders of adult personality and behaviour, whereas the DSM-IV (APA 2013) specifies that adolescents with BPD can be diagnosed if the features of the disorder have been present for at least one year (NICE 2008).  BPD is difficult to define and although a high percentage of people in a mental health setting may have been diagnosed with such a disorder, professionals are still undecided in their approach. It is very important to understand the above symptoms and borderline personality itself, as it can easily be misdiagnosed as another mental illness – particularly mood disorder (Arntz 1999). BPD is more likely to develop in women than men. It should also be noted that drug and alcohol use often occurs with personality disorders and also appears more apparent in those suffering with borderline personality disorder.

The cause of borderline personality disorder is still suggested as a grey area and complex. A strong thought is that the cause of BPD could arise from childhood abuse, neglect, separation from loved ones or caregivers. These are seen to be major contributing factors particularly if the abuse is severe and sustained (Leib et al, 2004). However, another school of thought is that BPD could run in families or that it may be related to a chemical imbalance in the brain (Alper 2001). Leib et al, (2004) agrees that  genetic components and adverse childhood experiences may cause childhood dysregulation leading to dysfunctional behaviours and conflicts later on in life. It is important to note that the United Kingdom is the only country in the world to have a health service in which personality disorders are considered to be of great importance. As a result, during 2003, it was decided to include the treatment of personality disorders as part of the service. The development of these services remains inconsistent and in some cases undeveloped (NICE 2008).

The implementation of relevant legislation and guidelines has been set out in England and Wales to support all who meet the criteria of BPD. The National Institute for Health and Clinical Excellence (NICE 2008) draft consultation document has commissioned a clinical guideline for anyone that has developed this disorder. Aims set out by this document include the evaluation of specific psychosocial and pharmacological interventions regarding treatment, whilst providing choice, best practice and advice for care and treatment of the individual. Raising the Standard: The Revised Adult Mental Health National Service Framework and an Action Plan for Wales (WAG 2005) sets out guidelines relating to the diagnosis of BDP using the DSM- 1V (APA 2013) and criteria to combat over- diagnosis. These guidelines lay down paramount importance on the delivery of client centred care. If the usual treatment is not sufficient, the drug treatment must be tailor made to meet the individual’s needs with BDP and then combined with psychotherapy or behavioural strategies to be effective. All team members involved must be educated fully in the presentation of BDP and it is vital that the team approach is integrated to provide consistency.

Still to this day psychotherapeutic treatment of this patient group remains one of the most challenging for our mental health professionals. The underlying dynamics of this complex disorder and common lack of understanding leave patients diagnosed with BPD extremely difficult to engage and work with. Clients with BPD continue to significantly utilise medical and psychiatric care. Their symptoms of self-destruction, anger, mood instability and impaired interpersonal relationships can hinder their development of a therapeutic alliance and successful treatment outcome. When dealing with this group of individuals staff may have feelings of stress, anxiety, confusion, loss of achievement and  may find it difficult to move away from what is familiar to them or to the unknown (Marquis and Huston 2006). 

However, In more recent years the development of therapeutic models by practitioners such as Meares (Meares et al. 1999) and Linehan (1993a; 1993b) has provided a basis for focused therapy for which there is increasing evidence of successful outcomes. Effective treatment strategies for BPD with a central focus on the implementation of interventions using the concepts of Dialectical behavioural therapy (DBT) has been proven to build effective coping strategies and skilful behavioural responses for improved quality of life. According to the American Psychiatric Association (2013) practice guidelines, DBT is a psychotherapeutic approach that has been shown to be effective in randomised trials.

The Welsh Assembly Government (WAG) (2005) state that support should be in place for all staff at all levels to help cope with this challenging group of clients. As research continues and more sufferer’s of BPD continue to experience a better quality of life armed with more robust coping skills, the future for this client group and the expansion of DBT services appears brighter.

If you have a client, or know of someone who is struggling to find the right help for borderline personality disorder, reach out to us at Khiron Clinics. We believe that we can improve therapeutic outcomes and avoid misdiagnosis by providing an effective residential program and out-patient therapies addressing underlying psychological trauma. Allow us to help you find the path to realistic, long lasting recovery. For information, call us today. UK: 020 3811 2575 (24 hours). USA: (866) 801 6184 (24 hours).

References

Alper, G Peterson S J (2001) Dialectical Behavior Therapy for Patients with Borderline Personality Disorder. Journal of Psychosocial Nursing and Mental Health Services. 39 10.

American Psychiatric Association (2000) Diagnostic and Stastisical Manual of Mental Disorders. (4th edn.) DSM-IV. Washington DC: APA.

Arntz A (1999) Do personality disorders exist? On the validity of the concept and its cognitive-behavioural formulation and treatment. Behaviour Research and Therapy.37 97- 134.

Crane J.T (2017) The Trauma Heart. Florida: Health Communications, Inc.

Gunderson, J G & Kolb J E (2008) Discriminating features of borderline patients. American  Journal of Psychiatry. 135 792-796 Lieb, K Zanarini, M C Schmahl, C

Linehan, M Bohus M (2004)  Borderline Personality Disorder. The Lancet: 364, 9432, RCN Edition: Pro-Quest Nursing and Allied Health Source. 453

Marquis, B L & Huston (2006) Leadership Roles in Management Functions in Nursing. (6thedn.). Philadelphia: Lippincott: Williams & Wilkins.

National Institute of Clinical Excellence (2008) Borderline Personality Disorder: Treatment and Management. A draft Consultation.

http//www.nice.org.uk/guidance/index.jsp?action=folder&o=4039 Accessed 16/06/08.

Otong.A (2003) Evidence-Based Care of the Patient with Borderline Personality Disorder. 2016 Jun; Vol. 51 (2), pp. 299-308.

Welsh Assembly Government (2005) Raising the Standard: The Revised Adult mental Health National Service Framework and Action Plan for Wales: Welsh Assembly Government. Linehan M (1993) Cognitive Behavioral Therapy of Borderline Personality Disorder. New York: Guildford Press

World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO.

Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL. (1989). The Revised Diagnostic Interview for Borderlines: discriminating BPD from other axis II disorders. J Personal Disord.: 3:10–18.

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