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Borderline Personality Disorder And Childhood Trauma

We can say, with a very considerable degree of confidence indeed, that there exists a strong link between borderline personality disorder and childhood trauma; a large body of research has shown that individuals who have suffered childhood trauma and/or neglect are far more likely to develop borderline personality disorder (BPD) as adults than those who were fortunate enough to have experienced a relatively stable childhood.

Before we look at how borderline personality disorder and childhood trauma are linked, it is first useful to briefly describe the main symptoms of this most serious psychological disorder.

WHAT IS BORDERLINE PERSONALITY DISORDER (BPD)?

Borderline personality disorder experience a range of symptoms which are split into 9 categories. These are:

1) Extreme swings in emotions
2) Explosive anger
3) Intense fear of rejection/ abandonment sometimes leading to frantic efforts to maintain a relationship
4) Impulsiveness
5) Self-harm
6) Unstable self-concept (not really knowing ‘who one is’)
7) Chronic feelings of ’emptiness’ (often leading to excessive drinking/eating etc ‘to fill the vacuum’)
8) Dissociation ( a feeling of being ‘disconnected from reality’)
9) Intense and highly volatile relationships

For a diagnosis of BPD to be given, the individual needs to meet at least 5 of the above borderline personality disorder criteria.

A person’s childhood experiences have an enormous effect on his/her mental health in adult life. How parents treat their children is, therefore, of paramount importance.

A borderline personality disorder is an even more likely outcome, if, as well as suffering trauma through dysfunctional parenting, the individual also has a BIOLOGICAL VULNERABILITY.

In relation to an individual’s childhood, research suggests that the 3 major risk factors are:

– trauma / abuse
– damaging parenting styles
– early separation or loss (e.g due to parental divorce or the death of the parent)

Of course, more than one of these can befall the child. Indeed, in my own case, I was unlucky enough to be affected by all three. And, given my mother was highly unstable, it is very likely I also inherited a biological/genetic vulnerability.

EXAMPLES OF DAMAGING PARENTING STYLES:

1) Dysfunctional and disorganized – this can occur when there is a high level of marital discord or conflict. It is important, here, to point out that even if parents attempt to hide their disharmony, children are still likely to be adversely affected as they tend to pick up on subtle signs of tension.

Chaotic environments can also impact very badly on children. Examples are:

– constant house moves
– parental alcoholism/illicit drug use
– parental mental illness and instability/verbal aggression

2) Emotional invalidation. Examples include:

– a parent telling their child they wish he/she could be more like his or her brother/sister/ cousin etc.
– a parent telling the child he is ‘just like his father’ (meant disparagingly). This invalidates the child’s unique identity.
– telling a child she or he shouldn’t be upset over something, therefore invalidating the child’s reaction and implying the child’s having such feelings is inappropriate.
– telling the child he or she is exaggerating about how bad something is. Again, this invalidates the child’s perception of how something is adversely affecting him or her.
– a parent telling a child to stop feeling sorry for him or herself and think about good things instead. Again, this invalidates the child’s sadness and encourages him/her to suppress emotions.

Invalidation of a child’s emotions, and undermining the authenticity of their feelings, can lead the child to start demonstrating his/her emotions in a very extreme way in order to gain the recognition he/she previously failed to elicit.

3) Child trauma and child abuse:

People with BPD have very frequently been abused. However, not all children who are abused develop borderline personality disorder due to having a biological/genetic RESILIENCE and/or having good emotional support and validation in other areas of their lives (e.g. at school or through a counselor).

The trauma inflicted by a family member has been shown by research to have a greater adverse impact on the child than abuse by a stranger. Also, as would be expected, the longer the traumatic situation lasts, the more likely it is that the child will develop borderline personality disorder in adult life.

4) Separation and loss:

Here, the trauma is caused, in large part, due to the child’s bonding process development being disrupted. Children who suffer this are much more likely to become anxious and develop ATTACHMENT DISORDERS as adults which can disrupt adult relationships and cause the sufferer to have an intense fear of abandonment in adult life. They may, too, become very ‘clingy’, fearful of relationships, or a distressing mixture of the two.

 

Borderline Personality Disorder (BPD) Statistics, Facts, and Figures :

– about three-quarters of those who suffer from BPD have a history of self-harm 

– about 10% of those who suffer from BPD eventually commit suicide 

– the majority of those who suffer from BPD improve over time (over 70% go into long-term remission). 

– about 50 -60% of those with BPD have a history of having been sexually abused

– one of the main hallmarks of BPD is severe dissociation 

– a diagnosis of BPD does not define the person nor detract from their positive qualities

– psychotherapy, especially Dialectical Behaviour Therapy (DBT), has been shown by studies to be the most effective treatment 

– if a person suffers from BPD, s/he is likely to have other mental health issues that run alongside it (known as co-morbidities). Often, these other conditions include depression, psychotic symptoms, and bipolar disorder

– about half of those who suffer from BPD have experienced a history of having been the victim of violence

– about 1% of the population suffers from BPD; whilst it is just as likely to affect men as women, the condition is under-diagnosed in men who are more likely to become caught up in the justice system or to use substance abuse services instead of having their BPD directly addressed.

Neuroimaging And Borderline Personality Disorder (BPD) :

Are the brains of people with borderline personality disorder (BPD) physically different from the brains of those without BPD? Neuroimaging techniques can help to answer this question.

What Is Neuroimaging?

Neuroimaging incorporates various techniques which take images of the brain’s structure and functioning. However, there is controversy surrounding just how accurately such images may be interpreted.

Neuroimaging techniques include :

  • Magnetic resonance imaging, or MRI (this technique uses magnetic fields and radio waves to produce two or three-dimensional images of the brain).
  • Positron emission tomography, or PET (this technique also produces two or three-dimensional images by measuring emissions from radioactive chemicals that have been injected into the bloodstream)
  • Magnetoencephalography (this technique measures the magnetic fields produced by electrical activity in the brain).

Meta-analysis Of Neuroimaging Studies Relating To Borderline Personality Disorder (BPD) :

Researchers at the University of Freiburg (2006) conducted a meta-analysis (an overarching analysis of relevant, previously published studies) of all the research to date (i.e. 2006, see above) relating to BPD and neuroimaging.

They found that all of these studies found abnormalities in :

  • the limbic system (a region of the brain involved in generating emotions including fear, anger, and those connected with sexual behavior, the formation of memories, especially memories connected with intense emotions)
  • the frontal lobes (a region of the brain involved in functions including understanding the consequences of actions, decision making, the regulation (control) of emotions, and the suppression of unacceptable social impulses (including impulsive aggression).

Conclusion :

These abnormalities in these two regions of the brain, given the functions of those regions, are consistent with symptoms found in individuals suffering from BPD. It can, therefore, be inferred that the limbic system and frontal lobes are involved with the disorder.

However, research (at the time of writing) is not advanced enough to enable the actual diagnosis of BPD using neuroimaging techniques.

Common Misunderstandings About Borderline Personality Disorder : 

Due to the fact that borderline personality disorder (BPD) is a highly complex condition, there are, notoriously, many misunderstandings and misconceptions surrounding the true nature of this extremely serious psychiatric illness; they include the following :

1) The condition is untreatable – unfortunately, until relatively recently, many of those working in the field of mental health regarded BPD as essentially untreatable. It is very sad that this meant a lot of individuals were left to suffer extreme distress which could, with proper treatment, have been alleviated.

Fortunately, there is now much research showing that, in fact, treatment can be very effective for those suffering from BPD. Other therapies for BPD, include :

  • STEPPS
  • Mentalization-Based Therapy (MBT)
  • Intensive Short-Term Dynamic Therapy
  • Dynamic Deconstructive Therapy (DDT).

Indeed, approximately three-quarters of those who receive proper treatment will improve so significantly that they no longer meet the criteria to be diagnosed with BPD.

2) Stigmatization – It is true that there is still a significant stigma surrounding the diagnosis of BPD, but things are improving.

It used to be the case that many mental health professionals even refused to work with BPD sufferers because they were regarded as too difficult and challenging. This situation has greatly improved due to the much better understanding that now exists surrounding what compels BPD sufferers to behave the way they do and how this behaviour is very often linked to intense feelings of distress and having suffered a deeply painful childhood.

3) Diagnosis –  In the past, psychiatrists frequently did not even like to diagnose their patients with BPD because they did not wish to stigmatize them. Again, now, with the accruing of much greater understanding and knowledge about both the causes and true nature of the condition, psychiatrists are not so likely to be deterred from diagnosing the illness.

There is, in fact, a great value in receiving a correct diagnosis of BPD, as it allows the sufferer to understand the source of his/her difficulties and what may have caused them (click here to read my post about the link between childhood trauma and the subsequent development of BPD,) therefore making it far more likely that these difficulties can be effectively addressed. Learning about one’s illness and its likely causes means that an individual no longer needs to fight it with ‘one hand tied behind their back’

4) The misconception that those who suffer from BPD are deliberately manipulative – it used to be claimed by some that individuals with BPD had a tendency to be deliberately manipulative. In fact, however, when BPD sufferers become intensely angry, for example, or otherwise ‘act out’. it is generally the case that such behavior is impulsive, spontaneous, and completely unplanned.

Indeed, because one of the symptoms of BPD is an impaired understanding of how social interaction operates, they are unlikely to have the necessary skills to plan out the intricacies of how to approach others in a manipulative and self-serving way.

5) The misconception of ‘attention-seeking’ suicide attempts – the fact of the matter is, an absolutely astounding ten percent of individuals with BPD ultimately end their lives by suicide. THIS SUICIDE RATE IS ONE THOUSAND TIMES GREATER THAN IN THE GENERAL POPULATION IN THE UK! That statistic speaks most eloquently for itself, I think. Given this horrendous figure, one is left wondering, and deeply bewildered, as to why those with BPD do not demand MUCH MORE ATTENTION, LEFT AS THEY ARE, SO OFTEN, TO FEND FOR THEMSELVES WITH NO PROPER MEDICAL INTERVENTION.

Study Shows 73% Recover from Borderline Personality Disorder (BPD):

Until recently, it was frequently suggested that borderline personality disorder (BPD) was very difficult, if not impossible, to treat. During my research for this article, I have been disturbed to discover, also, that in the recent past some clinicians did not regard BPD as an illness at all – instead, they put forward the view that those diagnosed with BPD were not mentally disordered, but, rather, simply ‘bad’ and ‘manipulative’ people!

This reminds me of a time I made a very serious and determined suicide attempt and the psychiatrist I saw afterwards (who knew very little about me) tried to make the case that I had not really intended to kill myself but was seeking attention and sympathy. When I protested and tried to explain the attempt had been made very much in earnest (one might even say, ‘deadly earnest), he responded (and I quote him verbatim: ‘It sounds like you’re talking bullshit to me!’

Highly professional.

In connection with the cynical and deeply insulting attitude that my psychiatrist displayed, I would also point out that, in my own personal view, some individuals (in my case, certain family members and former friends) like to take the view the BPD sufferer is not really ill as this, in their minds, absolves them of any responsibility to provide help and support.

Despite such pessimism, a study funded by Columbia University found that 73.5% of the participants who took part in their study recovered from BPD within 6 years. Even more encouragingly, it was found in the same study that more than half actually recovered within just 2 years.

Another encouraging finding of the study was that only 6% of those who had recovered relapsed (and, even if they did, this was mainly due to the effects of an extremely stressful event/s).

FURTHER RESULTS FROM THE STUDY :

– 1.4% of the participants committed suicide in the first 2 years of the study

– 1.7% of the participants committed suicide in the next 2 years of the study

– 0.7% of the participants committed suicide in the final 2 years of the study

(This gives a total of 3.8%, or about 1 in 25, who committed suicide during the study).

– 65.9% achieved good psychological functioning by the end of the study (32.4% after 2 years, 48.3% after 4 years, 65.9% by end of the study).

SPECIFIC SYMPTOMS THAT IMPROVED IN THE INDIVIDUALS IN THE STUDY :

– Impulsiveness (this symptom improved best of all)

– Mood/affect (although this improved least well)

– Interpersonal functioning

– Self-mutilation

– Suicidal behaviors

– Psychotic symptoms

The study also showed that the two factors which most helped the individuals to recover were :

1) Ending a destructive relationship

2) Determination to get well.

BPD Resources And Links

 

 

 

Dialectical Behavior Therapy For The Treatment Of BPD

File:DBT Skills 1 Narrow.png - Wikimedia Commons

Above image: Creative Commons Licence

 

DIALECTICAL BEHAVIOR THERAPY (DBT), which helps individuals develop skills of mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness (see diagram above for more detail) is an exciting, relatively new treatment option for those suffering from BPD. It is a therapy that has elements in common with cognitive-behavioral therapy (CBT).

It is an evidence-based treatment (ie it is backed by scientific research).

Dialectical behavior therapy (DBT) is a type of therapy specifically designed to treat people with BPD and, whilst it is made up of many elements, four, in particular, stand out as vital for the treatment to be effective. These are as follows:

  1. The BPD sufferer is recognized as being highly emotionally vulnerable and hyper-reactive to even minor stressors.
  2. The BPD sufferer grew up in an environment in which his/her emotional responses were invalidated and dismissed (e.g. being told by a parent to stop being a ‘silly cry-baby’ when distressed) leading to a vicious circle whereby the BPD sufferer was made to feel guilty and wrong for experiencing such emotions serving to intensify them yet further.
  3. DBT aims to validate the BPD sufferer’s emotions and to reassure him/her that such emotions were valid, real, and acceptable.
  4. Encourage the BPD sufferer to see that most things in life are not ‘black or white’ but more nuanced and to understand the importance of being open to new ideas and opinions which contradict their own and reduce ‘rigid thinking’ with the ultimate goal of helping them to develop a fresh perspective on their relationships with others and life and the world in general that, in turn, reduces their tendency to behave in ways that are destructive to others and to themselves.

In the past, BPD was considered to be extremely difficult to treat, but, with the development of therapies such as CBT and DBT, the prognosis is now far more optimistic.

DBT was originally created by the psychologist Marsha Lineham; at first, it was developed with the treatment of females who self-harmed and were suicidal in mind. However, since then, its possible applications have become much broader; it is now used to treat both males and females suffering from a large array of different psychological conditions. These include:

– self-harming
– depression
– suicidal ideation
– bipolar
– anxiety
– PTSD
– eating disorders
– substance abuse
– low self-esteem
– problems managing anger
– problems managing relationships/friendship

DBT has many elements in common with CBT; in addition to this, it also borrows from ZEN and a therapy, which is becoming increasingly popular, called MINDFULNESS.

DBT has been particularly successful in the treatment of  BORDERLINE PERSONALITY DISORDER. It is thought that one of the main CONTRIBUTING FACTORS of BPD is a traumatic childhood in which the child grows up in an INVALIDATING ENVIRONMENT and is made to feel, bad, guilty and worthless Such a childhood environment is especially likely to result in the child developing BPD in later life if he/she also has a BIOLOGICAL VULNERABILITY (carries certain genes making him/her particularly vulnerable to stress).

When a person is suffering from BPD the condition causes him/her to REACT WITH ABNORMAL INTENSITY TO EMOTIONAL STIMULATION; the individual’s level of emotional arousal goes up extremely fast, and peaks at an abnormally high level, and, takes much longer than normal to return to its baseline level.

This condition leads to the affected individual – a victim of his/her uncontrollable, intense emotional reactions – being prone to stagger in life from one crisis to the next and to be perceived by others as emotionally unstable. It is thought that, due to the invalidating environment which the sufferer experienced in childhood, the normal ability to develop the coping strategies needed to regulate emotions is blocked, leaving the person defenseless against painful emotional feelings and leading to maladaptive (unhelpful/destructive) behaviors.

The therapy teaches individuals how to cope with, and regulate, their emotions so that they are no longer dominated and controlled by them. This is vital as the inability to control feelings will often wreck crucial areas of life, including friendships, relationships, and careers. It is because of these possible effects that DBT also helps individuals develop SOCIAL SKILLS to help reduce the likelihood of them occurring.

Although initially devised for the treatment of BPD, DBT has also been found to be effective in helping people suffering from a large range of psychiatric conditions.

 

 

 

DBT AND BRAIN FUNCTIONALITY:

 

DIALECTICAL BEHAVIORAL THERAPY (DBT), devised by Marsha Linehan,  the founder of Behavioral Tech, has been found to be particularly effective in treating those who, in part due to their childhood experiences, have gone on to develop BORDERLINE PERSONALITY DISORDER (BPD).

Five skills are central to dialectical behavioral therapy (DBT); these are as follows:

1) CORE MINDFULNESS
2) DISTRESS TOLERANCE
3) EMOTIONAL REGULATION
4) INTERPERSONAL EFFECTIVENESS

1) CORE MINDFULNESS:

DBT describes the mind as having 3 components (these are concepts, not actual, distinct, physical parts of the brain, obviously). The 3 components are:

a) the reasonable mind
b) the emotional mind
c) the wise mind

Let’s examine each of these in turn:

a) the reasonable mind: this can be summed up, according to DBT, as the part of the brain which acts according to reason, logic, and rationality

b) the emotional mind: according to DBT, this is the part of the brain which operates on the basis of our feelings (when the ‘heart controls the head’)

c) the wise mind: ideally, according to DBT, we should allow this part of the brain to guide us; it is A BALANCE BETWEEN 1 and 2 above when the reasonable and emotional brain is operating in HARMONY.

If we are able to operate in ‘wise mind mode’, this will mean we can maintain control and prevent ourselves from becoming a victim of our own intense emotions. In order to see the importance of this, we need only consider times in our lives when our behavior has been dominated by our emotions and the negative effects this may have led to. Indeed, not learning to control emotions can leave our lives in ruins, not least due to the frequent self-destructive effects of our emotional outbursts.

2) DISTRESS TOLERANCE :

Practitioners of DBT try to instill the view in their clients that sometimes it is easier, and psychologically healthier, to stop struggling against reality, and,(they tell us) we need to accept that we, nor anybody else, for that matter, can prevent painful events from occurring in life (sometimes extremely painful ones, if we’re going to be up-front about it), nor can the painful emotions they bring with them. It is hardly a new idea, but practitioners of DBT also remind us that some painful things in life cannot be changed and that the only viable option we really have, therefore, is to accept the fact. This, of course, is difficult and requires considerable inner strength. By accepting the things which cannot be changed, though, it is reasoned, we free up energy that could have been wasted (by, say, being angry and bitter about the existence of these unchangeable facts) to deal with what CAN BE CHANGED.

DBT therapists tell us that there are certain skills we may wish to develop which will INCREASE OUR ABILITY TO TOLERATE DISTRESS; these are:

a) distraction/improving the moment
b) self-soothing
c) considering the pros and cons of the situation
d) radical acceptance

Let’s briefly look at each of these in turn:

a) distraction/improving the moment – eg distracting ourselves with activities we enjoy, keeping our minds busy; reminding ourselves of the good things in life; reminding ourselves that it is better to think clearly and in a focused way about our problems ‘after the storm has passed’ (rather than try to make decisions when in the middle of an intense crisis which may be over-determined by our emotions); remind ourselves that difficult periods will pass

b) self-soothing – e.g. we can use positive self-talk; meditation/relaxation activities/breathing exercises; using our imaginations to recall a soothing and comforting memory or place (if recalling a place it can be helpful to imagine, for a while, actually being there); thinking of things in life which are meaningful to us and give us the motivation to get through the difficult period.

c) considering the pros and cons of the situation: e.g. we may wish to consider how getting through a very difficult period may benefit us – for example, we may learn from it, it may strengthen us, it may make us more compassionate and sensitive towards others, we may be able to pass on the benefit of our experience to help others, it may even open up completely unexpected avenues in life which may not otherwise have been available to us (bad events do sometimes lead to positive outcomes, however indirectly – it is often worth keeping that in mind).

d) radical acceptance: this might involve trying to view what is happening, however undesirable, from as objective and detached a perspective as possible – a bit like watching the events unfold around somebody else in a movie; another, perhaps surprising, technique suggested by DBT therapists is to try to, literally, half-smile. This sounds strange and even rather silly, but research shows that just as the mind can affect the body (eg thinking about something embarrassing and going red in the face) so too can the body affect the mind – in this case, the idea is that the half-smile ‘fools’ the brain into ‘believing’ things aren’t as bad as all that. It is obvious, however, that in certain situations this technique would be highly inappropriate (I need hardly list examples).

3) EMOTIONAL REGULATION :

The fourth skill that DBT teaches is how to cope with intense and overwhelming emotions – this skill is referred to by practitioners of DBT as emotional regulation.

This skill is made up of three sub-skills: a) increasing one’s understanding of one’s emotions; b) decreasing one’s emotional vulnerability; c) lessening the degree of distress caused by one’s negative emotions.

4) INTERPERSONAL EFFECTIVENESS :

The final skill of interpersonal effectiveness helps the person undertaking DBT to communicate with others effectively when interacting with others in a way that helps to improve his/her relationships.

In order to achieve this, s/he is helped to communicate with others in a more controlled manner and to be less prone to speaking impulsively and without forethought due to stress or overwhelming emotions (such as anger).

TAKING THE MIDDLE PATH:

This is a metaphor for avoiding the trap of constantly seeing issues in terms of BLACK AND WHITE (eg all good/all bad and a marked tendency to perpetually think IN TERMS OF EXTREMES). DBT stresses the importance of teaching ourselves to FOCUS MORE ON THE GREY AREAS and to try to take A BROADER RANGE OF PERSPECTIVES when considering issues, to think more FLEXIBLY, and to THINK LESS IN ABSOLUTE TERMS.

Taking the middle path, according to DBT, also involves BOTH VALIDATING OUR OWN THOUGHTS/FEELINGS AND THOSE OF OTHERS. Even if others don’t understand, DBT stresses that we need to comfort ourselves when distressed by reminding ourselves that how we are feeling is real and makes sense under the current circumstances we find ourselves in. We can remind ourselves, too, that no matter what others may think, NOBODY UNDERSTANDS US AS WELL AS WE UNDERSTAND OURSELVES (others can’t understand what it is ‘to be in our heads’; we should not be ashamed of how we feel). By applying this compassion and understanding to ourselves, as part of ‘taking the middle path’ it seems fair that we should extend similar understanding to others – we can accept what they feel, as non-judgmentally as possible, irrespective of whether we approve or not.

Research Suggests That DBT Can Beneficially Alter Brain Functioning :

THE STUDY :

Research conducted by Schnell and Herpertz (2006) involved looking at the effects of DBT (specifically, training in emotional regulation, see number 3, above) on female patients’ brain functioning (this was done by taking magnetic resonance images, or MRIs, a type of brain scan) after they had spent 12 weeks undergoing an inpatient treatment program.

RESULTS OF THE STUDY :

The female, BPD patients who improved following the DBT / emotional regulation skills 12-week inpatient program were found (by analysis of their MRIs) to show:

REDUCED ACTIVITY IN CERTAIN BRAIN REGIONS IS ASSOCIATED WITH THE GENERATION OF INTENSE EMOTIONS, INCLUDING THE AMYGDALA AND THE HIPPOCAMPUS.

Such a reduction of activity in these brain regions is associated with an increase in the individual’s ability to prevent themselves from overreacting to stressful situations (overreacting to stressful situations, also known as impaired emotional regulation, is one of the hallmark features of BPD).

Conclusion :

The above can be interpreted as further evidence of the effectiveness of DBT for treating patients suffering from borderline personality disorder (BPD).

 

Affiliate links

Useful Link :

A LINEHAN INSTITUTE TRAINING COMPANY

More BPD Resources And Links

 

 

 

 

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