Borderline personality disorder and trauma

3 minute read

Labelling patients with “borderline personality disorder” may contribute to a sense hopelessness about the condition


Labelling patients with “borderline personality disorder” may undermine the impact of the patient’s past trauma, and may contribute to a sense hopelessness about the condition, says a leading psychiatrist.

Professor Jayashri Kulkarni, director of Monash Alfred Psychiatry Research Centre, told the recent annual conference of the College of Pathologists in Sydney that borderline personality was “a useless term”.

“The essence of us is our personality, So if we tell a patient they have a personality disorder, we are taking away their capacity and what makes them, them,” Professor Kulkarni said.

Instead, there is a growing body of literature that links early childhood trauma, such as sexual, physical or emotional abuse or even disrupted attachment to a primary caregiver, to the development of this condition.

This suggested a term such as “complex trauma disorder” would be more appropriate, Professor Kulkarni said.

Around 85% of patients with borderline personality disorder had background of trauma, so explaining the impacts of complex trauma on development could be “quite profound” and a relief for patients, Professor Kulkarni said.

Borderline personality disorder is a highly prevalent condition, affecting around 6% of the population severely, and is characterised by impulsivity, emotional dysregulation and intense fear of abandonment.

Research in neuroscience now showed that the parent-baby interaction was “absolutely vital to development”, she said.

“With disrupted attachment, there are actual structural changes, particularly to the amygdala, hippocampus and some of the other subcortical structures, resulting in memory [disturbance] and other disturbances.”

Not recognising the association between borderline personality disorder and trauma meant medical professionals could often ignore or overlook the background history, Professor Kulkarni said.

“The anger and rejection that these people feel means that they are often labelled as bad, manipulative and attention seeking,” she said. “And it is common to have a push-pull dynamic in relationships with health professionals as well.”

While many medical professionals tried to avoid dealing with people with the disorder, GPs commonly were left to manage them.

“The patients who really do the best are the ones who have a nice, kindly general practitioner who is there, and who remains there. You don’t have to do brilliant analytical stuff, but you have to be constant.”

A very important first step for doctors seeing these patients was to validate them and their distress, and to provide recognition of what the person had experienced, Professor Kulkarni said.

It was common for patients to fly off the handle if their perceived symptoms or experiences were contested, she said.

“Underneath the rage and all of that, there is a very fragile person with poor self-esteem who is telling herself that she’s no good. Validate, validate, validate, we always say.”

Dismissing patients’ experiences or their reactions to medications could also feed into earlier memories of the trauma and not being believed, Professor Kulkarni said.

Good modelling was also effective, by following through with commitments and setting boundaries.

“It’s a really difficult condition to make a diagnosis in, because it can present in different ways,” she said, adding that patients were often misdiagnosed with depression, anxiety or schizophrenia, and consequently burdened with polypharmacy.

A name change of the condition was rebuffed by the latest DSM committee, but Professor Kulkarni was optimistic that the new ICD-11 would include a diagnosis for complex trauma disorder, potentially overlapping with post traumatic stress disorder.

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