Borderline Personality Disorder

The Impact of Psychological Trauma on
Personality:
Borderline Personality Disorder and Complex
Trauma Reactions
Dr Walter Busuttil
Consultant Psychiatrist and Medical Director
walter.busuttil@combatstress.org.uk
Aims
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Define Psychological Trauma
Define Complex Trauma Reactions
Define Borderline Personality Disorder
Define interaction between Personality and
Post Traumatic Stress Disorder and other
trauma related disorders.
PTSD
Extreme Traumatic Experience- out of the
range of normal experience, perceived with
intense fear, horror, helplessness.
Three core cluster symptoms:
• Re-experiencing
• HyperArousal
• Avoidance
A Dynamic Model for the Interaction
of the Symptom Clusters in Established PTSD.
Modified by Busuttil (1995) from Horowitz (1976) Information Processing Model
Stressor
Arousal
Re-experiencing
Avoidance
Simple & Complex PTSD
Simple PTSD
• Single Trauma
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Complex PTSD
Multiple Trauma
Traumatised Under age
of 26
Developmental stage
Attachments
Neuro-developmental
stage
Multiple Traumatisation
Considerations:
• Nature and Extent of Trauma
Personal
General
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Age and Developmental Stage
Reason / Cause / Ideology
Support - Group vs Isolation
Sustained - predictable / unpredictable
Intermittent
Traumatisation in Childhood
• Age
• Context - act of God /
act of Man?
• Multiple vs Single
• Dose response?
• Meaning
• Developmental Stage
• Brain development
• Attachments
• Open vs Secret
• Individual vs Group
• ABUSE:
• Physical vs Sexual vs
Emotional vs Mixed
• Perpetrator / Power,
Control, Choice.
• Drug induced state
• Systematic vs NonSystematic: Organized?
Eg Pornographic ring?
• Within an institution?
DSM-IV Complex PTSD Working Party
Study
• Multiple traumatisation below the age of 26
years predicted development of Complex
PTSD
• Exposure to Multiple traumatisation after the
age of 26 years did not predict Complex PTSD
Complex PTSD DSM-IV Field Trials Adult Survivors of CSA
(van der Kolk et al, 1994)
Alterations in 7 dimensions:
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Affect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation.
Attention & concentration: dissociation, amnesia, depersonalization
Self-Perception: helplessness, guilt, shame.
Perception of perpetrator: idealization of the perpetrator or feelings of vengeance.
Relationships with others: isolation, mistrust, victim role, victimization of others
Somatisation: GIT; CVS; Chronic pain, conversion etc.
Systems of meaning: despair, hopelessness, major changes to previously well held beliefs
Disorders of Extreme Stress Not Otherwise
Specified (DSM-IV)
(DESNOS) (Herman, 1992)
• Defined in Adult Survivors of Childhood Sexual
Abuse
• DESNOS + PTSD = Complex PTSD (1995/6)
Complex PTSD: A diagnostic framework- disturbance on three
dimensions (Herman, 1992; Bloom, 1997)
• Symptoms
• Characterological / personality changes
• Repetition of Harm
Complex PTSD Disturbance on Three Dimensions
(after Bloom 1999)
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Symptoms of : PTSD
Somatic
Affective
Dissociation
Characterological Changes of:
Control: Traumatic Bonding
Lens of Fear
Relationships: Lens of extremity-attachment versus withdrawal
Identity Changes:
Self structures
Internalized images of stress
Malignant sense of self
Fragmentation of the self
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Repetition of Harm
To the self - faulty boundary setting
By others - battery, abuse
Of others - become abusers
Deliberate self harm
DSH/Suicidality
• History of abuse is a powerful predictor of
suicidality, even more than a diagnosis of
depression (Read et al, 2001).
• CSA victims are more likely, as well to be
repeaters of suicidal attempts as compared to
PTSD sufferers who did not suffer sexual abuse
(Taylor et al, 1994).
• Self-harm by cutting is very common among
Complex PTSD sufferers & BPD (Busuttil, 2006a;
Busuttil, 2006b).
Just to clarify:
• CPTSD is not a diagnostic category in DSM-IV.
• Concept of DESNOS is defined as ‘associated
feature’ of PTSD
• DESNOS+PTSD =CPTSD
Differential Diagnosis - Multiple
Traumatisation
• Complex PTSD
• Borderline Personality Disorder
• Dissociative Disorders
• Enduring Personality Change After
Catastrophic Stress
•Psychotic Illnesses: Schizophrenia / Bip Aff Dis
Dissociative Disorders
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Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Syndrome
Dissociative disorder not otherwise specified
• NB: Dissociative symptoms also included in criteria for
ASD; PTSD & Somatisation Disorder. An additional
Dissociative Disorder diagnosis is not given if the
dissociative symptoms occur exclusively within one of
these disorders.
Enduring Personality Change after
Catastrophic Stress (ICD-10, 1992)
Prolonged exposure to life threat/s
PTSD may precede the disorder
features seen after exposure to threat:
• a hostile mistrustful attitude towards the world
• social withdrawal
• feelings of emptiness or hopelessness
• chronic feelings of being on edge or threatened
• estrangement
Childhood Trauma Recent Concepts
Developmental Trauma Disorder
in children & adolescents:
Diagnostic framework criteria:
• Exposure
• Triggered dysregulation in response to trauma
cues
• Persistently altered attributions and
expectations
• Functional Impairment.
Borderline Personality Disorder DSM-4
criteria
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Frantic efforts to avoid real / imagined abandonment
Intense unstable interpersonal relationships
Identity disturbance
Impulsivity - self damaging: driving, sexual, binge eating
Suicidal gestures / self mutilation
Affective instability
Chronic feelings of emptiness
Anger: intense / inappropriate / difficulty controlling
Transient Paranoid Ideation / Dissociation (stress related)
Apart from DSM-IV crtieria consider additional dimensions taken
from the Diagnostic Interview with Borderlines-Revised
(Zanarini et al, 1989; Zanarini 2005).
1. Affective psychopathology, including
• chronic intense dysphoria;
• mood reactivity or affective lability.
2. Cognitive psychopathology including
• overvalued ideas of worthlessness or guilt,
• depersonalization and derealization
• non-delusional suspiciousness and ideas of reference.
• Quasi-psychotic or psychotic–like symptoms (transient, circumscribed, and
reality based delusions and hallucinations)
• genuine delusions or hallucinations.
3. Serious Identity Disturbance – frequent shifts in partial identities that are
acceptable versus others that are negative.
4. Behavioural Disturbance or Impulsive Behaviour including:
• Self-mutilation,
• suicidality,
• substance misuse,
• disordered eating,
• promiscuity,
• verbal outbursts,
• spending sprees,
• reckless driving.
5. Interpersonal Psychopathology including,
• intense unstable relationships that shift between idealization and
devaluation;
– frantic efforts to avoid real or imagined abandonment;
– devaluation,
– manipulation;
– demandingness;
– entitlement,
– treatment regressions;
– special relationships;
– dependency and counter dependency,
– distortions of the truth,
– sadomasochistic tendencies
Aetiological theories for BPD are unclear.
• Early childhood environmental factors - important
(Silk et al, 2005).
• Psychoanalytical theory: The internal environment
of child who goes on to develop BPD is primitive
because as a child the person has experienced
situations that have either caused developmental
arrest or made them regress under stress.
• Regression occurs particularly in situations of
separation.
Attachment Theory
(Bowlby, 1979; Fonagy, 2002; Silk et al, 2005).
• Early environment of infants - reinforced by the
parenting received.
• Normal development requires degree of reciprocity in
early relationships: develops emotional regulation.
• The infant’s experience of various environmental cues
results in learning subjective feelings of security or
insecurity helps emotional responses and how to
maintain sense of homeostasis in difficult situations.
• Infant’s experiences with the caregiver become
organized into internalized working models of
attachment of the self with others. This becomes
prototype for the future attachments and
relationships.
Attachment Theory
(Silk et al, 2005).
Two patterns of disturbed attachment can occur:
1. Emotional over involvement with a parent, and
2. Role reversal with the parent
Gunderson (1996) considers that the BPD patient’s
inability to tolerate aloneness and a fear of
abandonment has its roots in insecure attachments.
Traumatic Exposure
• CSA: extremely common in BPD sufferers, rates
ranging between 16 to 75% (Silk et al, 2005).
• Some workers have linked PTSD with BPD by
virtue of the consistent presence of a history of
CSA, and see BPD as a residual syndrome that
develops after PTSD resolves in childhood.
• Others have seen BPD as leading to dissociative
disorders in adulthood (Stone, 2005).
• While similarities between CPTSD and BPD exist, clear
distinctive phenomena have been deduced (Gunderson,
1996; Gunderson & Sabo, 1996).
• In PTSD a propensity to self-imposed isolation is very
common, whereas BPD patients have intense
relationships and fears of abandonment.
• Also in CPTSD, PTSD symptoms are present and in some
cases of BPD especially in those with a negative history
of traumatic exposure, PTSD symptoms are absent
(Gunderson, 1996; Gunderson & Sabo, 1996).
BUT:
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Not all people subjected to repeated trauma in childhood or adulthood develop
PTSD or DESNOS. Some of those traumatized in childhood, go on to develop other
disorders such as borderline personality disorder or dissociative identity disorder
possibly without PTSD. This variability needs to be studied.
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family variables such as levels of family support and cohesion may be more
predictive of long term effects of abuse than the abuse-specific variables such as
the severity or duration of the abuse itself ( Alexander, 1992)
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Particular attachment patterns antecedent to the abuse itself may predict how a
child
responds
to
an
abusive
or
traumatic
experience….
a
disorganized/disorientated attachment in which the attachment figure is often the
source.
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While CSA is associated with severe long-term sequelae, there is no evidence of a
specific constellation of symptoms unique to sexual abuse victims.
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Flawed attachment organization sensitizes the child to later trauma (Fonagy et al,
2000). This would increase vulnerability to developing PTSD later in life (Chu, 1992;
Lauterbach & Varna, 2001).
Biological Theories
Biological Theories
Overlap BPD and PTSD
BPD:
• Neuro-imaging findings demonstrate that the most consistent
structural or functional findings in BPD patients are in frontal and
limbic regions (Lyoo, 2005).
• The amygdala has a key role in the fear response and emotional
processing and is implicated in the aetiology of PTSD as has been
discussed earlier.
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Stress and traumatic events have been reported to increase
cortisol levels and decrease brain neurotrophin factor.
• The amygdala and hippocampus are brain areas sensitive to
exposure to high levels of cortisol and therefore neurogenesis of
these structures may be hampered by the sustained high levels of
cortisol (Teicher et al, 2002, 2003; Lyoo, 2005).
Biological Theories
Overlap BPD and PTSD
PTSD:
• LIMBIC SYSTEM malfunction: mainly amygdala & hippocampus
(van der Kolk, 1996). Supported by PET provocation studies
(Pitman, 2000; Shalev, 2001).
• PET studies: pre-frontal, limbic and peri-occipital; non-dominant
hemisphere narrative centre (Broca’s area) malfunction.
• Malfunction of the emotional centres (the limbic system,
especially the amygdala); in combination with the malfunction of
the narrative centre; reflect respectively, the high emotional
loading of the content of the traumatic material, and the
difficulty in accurate recall and the ability to construct a coherent
trauma narrative.
• PET scan findings reflect difficulty patients have when attempting
to disclose their traumatic stories coherently (Pitman, 2000;
Shalev, 2001; Hull, 2002).
Similarities in constructs of BPD and PTSD (John Briere,2002)
• PTSD: intrusive feelings, thoughts, and memories triggered by
stimulus, often followed by attempts to avoid such triggers or their
emotional effects.
• Borderline personality disorder: additional problems with identity
and self-other boundaries, and often sudden emotional outbursts,
self-defeating cognitions, feelings of emptiness and intense
dysphoria, and impulsive, tension-reducing behaviour. These are
triggered by perceptions of having been abandoned, rejected, or
maltreated by another person.
• The "borderline" person is often viewed as having problems in
impulse control, and as being emotionally over reactive to
perceived losses or maltreatment, responding with angry affect and
sudden, ill-considered behaviour.
A comparative example, (Briere 2002)
• A Vietnam veteran with PTSD might have intrusive sensory reexperiences of a combat scenario after being triggered by the sound
of a car backfiring, and, upon experiencing the Vietnam era fear
associated with the combat memory, engage in attempts to find
safety.
• An individual with borderline personality disorder, after being
triggered by a perceived slight in an intimate relationship, might
experience sudden, intrusive thoughts and feelings of abandonment
and betrayal associated with childhood maltreatment, and reexperience abuse-era desperation and anger associated with that
memory. The individual might then engage in dramatic negative
tension-reducing or proximity-seeking behaviour in the context of
that relationship.
• Both are having posttraumatic reactions that involve reliving a
previously traumatic event, although the relational components of
the latter are often seen, instead, as evidence of a personality
disorder.
Diagnosis
• Diagnosing CPTSD presents challenges. It must
be distinguished from BPD although overlaps
exist. – take a trauma history? May not tell
you!
• Co-morbid psychotic depression or psychoses
generated following substance misuse are
common.
• Schizoaffective disorders, schizophrenia and
manic depression need to be considered in a
differential diagnosis (Sareen, et al, 2005).
DSM-V / ICD-11
• High controversy as to whether separate diagnostic
category required for Complex PTSD
• Developmental Trauma Disorder in children (DTD)
will probably be included - but ?
• Personality Disorders category being restructured
and may be included under axis 1
• Disorders of affective instability? Or emotional
regulation?
Treatment of Complex PTSD: basic Principles
(Herman 1992)
• Stabilization & Safety
• Working through of Traumatic material – disclosure
– psychotherapy
• Rehabilitation
Treatment of Borderline PD with or without history of
trauma exposure
• Stabilization & Safety – SKILLS TRAINING
(Dialectic Behaviour Therapy / STEPPS)
If trauma has been perpetrated :
• Working through of Traumatic material – disclosure –
psychotherapy: Trauma Focussed-CBT/Eye Movement
Desensitisation and Reprocessing (EMDR) other TF Therapies
If no trauma:
• CBT/Schema Focussed therapy
• Rehabilitation
Reading list
• Briere & Scott (2006) Principles of Trauma Therapy. A guide
to symptoms evaluation and treatment. Thousand Oaks, CA
Sage.
• johnbriere.com
• Briere & Langtree (2008) Integrative treatment of complex
trauma for adolescents (ITCT-A).
• Busuttil, W. (2009) Complex PTSD: A useful diagnostic frame
work? Psychiatry, 8:8, 310-314.
• De Zulueta F, (2006) Inducing traumatic attachment in
adults with a history of child abuse: forensic applications.
Brit J Forensic Practice, 8,(3 )4-15
Recommended reading
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Effective treatments for PTSD. ISTSS Practice Guidelines (2009) eds Foa, E Keane &
Friedman, M J. Guilford Press: New York.
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Innovative Trends in Trauma Treatment Techniques. (2007) (eds M B Williams & J
Garrick). Howarth Press: New York, USA.
•
M Nasser, K Baistow & Treasure J (2007)When the Body Speaks its Mind. The Interface
between the Female Body and Mental Health. Routledge: London.
•
Luxenberg, T., Spinazolla, J., Hidalgo, J., Hunt, C. & Van der Kolk, B. (2001). Complex
Trauma and Disorders of Extreme Stress (DESNOS) Part Two: Treatment. Directions in
Psychiatry, 26, pp. 395-414.
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Van der Kolk, B., Roth, S, Pelcovitz, D., Sunday S. & Spinazolla, J. (2005). Disorders of
Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal
of Traumatic Stress, 18 (5), pp. 389-399.
References
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Bloom, S. (1997) Creating Sanctuary. Toward The Evolution Of Sane Societies. London: Routledge,
•
Briere J & Scott C (2006) Principles of Trauma Therapy, A Guide to Symptoms, Evaluation and
Treatment. Thousand Oaks, CA: Sage
•
Busuttil, W (2006) The development of a 90 day residential program for the treatment of Complex
Post Traumatic Stress Disorder. Book Chapter (eds M B Williams & J Garrick ). In Innovative Trends
in Trauma Treatment Techniques. Howarth Press: New York, USA.
•
Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When the Body
Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56, (eds M
Nasser, K Baistow & J Treasure). Routledge: London.
•
Cloitre M, Courtois, C., Charuvastra et al, (2011) Treatment of Complex PTSD: Resulta of the ISTSS
Expert Clinician Survey on best practices. J Traum Stress 24, 615-627
•
Kinniburgh, K.L., Blaustein, M., Spinazzola, J et al (2005) Attachment, self regulation and
competency. Psychiatric Annals 35, 424-430.
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Sareen, J. Cox, BJ Goodwin, RD et al, (2005) Co-occurrence of Post Trauamtic Stress Disorder in a
nationally representative sample. Journal of Traumatic Stress, 18, 313-322
•
Zanarini, M. C. (2005) The subsyndromal phenomenology of borderline personality disorder. In
Borderline Personality Disorder.(ed M C Zanarini) pp19-40. Taylor Frances Group. London.