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Borderline personality disorder has been and remains one of the most stigmatized conditions. A new look at it can destroy the stigma, and at the same time inspire specialists to search for new ways of healing.
If a film were made about Anna, a single mother of three daughters, the average viewer would most likely consider what they saw was too much and a collection of movie clichés.
Anna is in her forties, born and raised in East Germany, an hour from Berlin, and spent her childhood surrounded by alcoholics. The father and mother abused the girl, both emotionally and physically. As a teenager, she was raped several times, and she also lost a close friend — she became pregnant and was killed by her own father.
Now Anna recalls that most of all of the above she was hurt by the behavior of her parents — it seemed that they simply did not care about her. For example, when Anna told her mother about the rape, she replied that the girl herself was to blame, and her father, in front of whom her daughter had once been hit by a car, only hurried her on: “It’s okay, get up, you’ll be late for work.”
It is not surprising that Anna, according to her own recollections, grew up embittered and aggressive, did not know how to control emotions, and in her teens tried to commit suicide twice.
Growing up, she continued to behave «on the edge»: driving too fast and engaging in self-harm, cutting herself
Until now, she is not good at coping with problems in a healthy way: emotions are overwhelming, and the woman is afraid that “she can do something to herself.”
Anna is currently being treated for both post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD), a condition characterized by intense, unstable emotions that affect a person’s self-image and relationships, and is often accompanied by self-harm and suicidal behavior. .
PTSD and BPD are similar in many ways: patients with these diagnoses have the same difficulty in controlling their emotions, and they also have a disturbed sense of their own “I”. The key difference is that trauma has always been considered the cause of the development of PTSD, while the roots of borderline personality disorder were not clear to psychologists and psychiatrists for a long time.
Research, however, shows that between 30% and 80% of people with BPD have also experienced a major trauma that may have caused their disorder.
Perhaps the problem for a long time lay in the fact that experts understood the concept of «trauma» too narrowly.
What does it change? At a minimum, the treatment of patients with borderline personality disorder — even doctors have long considered them «difficult», prone to manipulation and resistant to treatment. But the fact that it may not be about a personality disorder, but about a condition caused by a serious injury, can fundamentally change everything. However, first things first.
BLURED BORDERS
When Bohus, now a successful psychiatrist in his early 60s, was practicing in a psychiatric hospital in Germany, he saw a woman sitting on the floor and drawing blood from self-inflicted wounds on the wall. After telling the senior psychiatrist about the patient, Bohus heard in response: “Oh, she’s just a“ border guard ”, do not pay attention. You can’t help her anyway. And no, people like her never commit suicide. It’s just an attempt to get attention.»
Bohus did as his senior comrade told him to. Soon the woman took her own life.
For what happened, the psychiatrist blames the conservative and paternalistic attitude towards patients that existed in those days. Especially to the «border guards».
By the way, this term itself was coined back in the 1930s by the German-born American psychiatrist Adolf Stern: this is how he described a condition on the border between neurosis (a mental illness like depression or anxiety that is not accompanied by hallucinations or delusions) and psychosis, in which patients lose touch with reality. Working with border guards using the usual psychotherapeutic methods, according to Stern, was extremely difficult.
However, the official diagnosis of borderline personality disorder did not begin until the 1970s. Psychiatrist John Gunderson, after studying patients who were falsely diagnosed with schizophrenia, identified six distinctive features of the «new» disorder:
vivid emotions, mostly hostile or depressive,
impulsive behavior
short episodes of psychosis
chaotic relationships with others
illogical thinking,
the ability to maintain a semblance of «normality».
Shortly thereafter, in 1980, the disorder was included in the Diagnostic and Statistical Manual of Mental Disease — the main document that guided psychologists and psychiatrists of the time — and this allowed them to finally start looking for suitable treatments (in addition, Gunderson and colleagues just proved that the healing of people with such a diagnosis is possible).
This disorder is most often diagnosed in women.
Although there is every reason to believe that both sexes are equally affected, it is just that women are more likely to seek help.
The controversy surrounding this pathology has not subsided so far: some experts consider it unique and associated with the patient’s trauma, others — only one of the variations of a personality disorder, and still others adhere to an intermediate explanation. For example, clinical psychologist Julian Ford believes that “there is ample evidence that trauma plays a role in almost every personality disorder, but what role remains to be seen.”
PEOPLE WITHOUT «EMOTIONAL SKIN»
Bohus recalls that in his youth, patients with BPD were treated in different ways: some doctors preferred to isolate them from the rest and drug them, treating them with undisguised suspicion and even hostility; others were supportive, warm, allowed to interact with other patients, and taught how to deal with stress. According to Bohus, such patients showed significant signs of improvement.
Alas, clinical psychologist Marsha Linehan fell into the first category: shortly after graduating from high school, the girl was diagnosed with BPD. She was sent to a psychiatric clinic, where she inflicted numerous injuries on herself — banging her head against the walls, extinguishing cigarettes with her hands and cutting them. Her doctors tried a lot: strong drugs, electric shock and cold therapy (the girl was fixed on the bed and covered with ice sheets), but all this, according to Linehan, harmed rather than helped.
The experience, which the woman describes as «a living hell,» motivated her to dedicate her life to helping others.
According to Linehan, the driving force behind this disorder is a complete dysregulation of one’s own emotions. “Borderline patients can be compared to third-degree burns: they just don’t have ’emotional skin’. Even the slightest touch can cause them unbearable pain, leading to a state of despair, rage or shame.
Linehan developed a new system of therapy called Dialectical Behavioral Therapy (DBT). It is based on the desire to simultaneously accept the patient and help him change his destructive behavior. Clinical studies have shown that this approach significantly reduces the key manifestations of borderline personality disorder, such that treated patients are less likely to end up in hospitals and injure themselves.
Although the approach has proven to be extremely effective, it does not work with one important aspect — all with the same injury.
INJURY WITH A CAPITAL LETTER
It wasn’t until 1980 that the diagnosis of PTSD was formalized as the first disorder unequivocally caused by external causes. Although the cases of post-traumatic stress disorder themselves have been known since the First World War.
In the early 1990s, Harvard psychiatrist Judith Herman, after reviewing a wealth of literature on trauma survivors, came up with a new diagnosis: complex PTSD. Such a diagnosis, in her opinion, should be made to patients who have experienced stress due to being at the mercy of other people: both in camps and prisons, and in especially destructive families. These patients have difficulty managing their emotions, are prone to self-harm, their self-image is severely damaged, and relationships with others are highly unstable.
And again a heated discussion ensued: many were confused by the fact that Herman’s listed symptoms intersected with signs of BPD.
Experts divided into two camps: some argued that PTSD was unfairly pathologised as a personality disorder, while others believed that although many people with BPD did experience trauma, this does not explain their behavior in general.
The main question that appeared on the agenda: what can be considered an injury? Although some patients, including Anna, mentioned at the beginning of the material, did have a traumatic experience, nothing like this happened to others.
In the fifth and most recent version of the Diagnostic and Statistical Manual of Mental Illness, trauma refers to cases where a person directly experienced or witnessed life or health threatening events, or was a victim or eyewitness of sexual violence. This means that those who witness domestic violence, and, for example, police officers who regularly encounter the cruelty of this world, experience trauma.
Although the official definition has appeared, it still has not become clearer, and many suggest that everything described above be considered Trauma with a capital letter, and cases of verbal abuse, neglect, bullying and poverty simply be called trauma. This makes sense: trauma (with a small “t”) is, alas, extremely common: a study in the United States shows that two-thirds of American adults have had some kind of traumatic experience.
At the same time, even “less serious” injuries, especially those inflicted in childhood, leave a tangible mark on the human brain.
Thus, verbal abuse in childhood leads to changes in the auditory cortex of the child’s brain, which at a later age can result in problems with wording. In addition, trauma causes shrinkage of the hippocampus (a structure associated with memory and learning), increased activity in the amygdala (the center of emotional regulation), and disruption of connections between these and other areas of the brain.
Scientists have found that both patients with BPD and those who have experienced trauma (with a large or small «t»), there are common neurobiological changes: structural and functional anomalies in the limbic system, which just includes the amygdala and the hippocampus. One of their constructive suggestions is to help patients «train» the amygdala by learning to control their brain activity in real time.
Some researchers, however, advise not to forget about other causes of the development of the disorder, in addition to trauma, for example, hereditary factors (their influence is clinically confirmed). Perhaps a child with a «bad» heredity is more likely to encounter traumatic events, and due to his «genetic inheritance» and cope with them with difficulty.
A kind of vicious circle is formed: a sensitive person reacts impulsively to situations in which he is hurt, and, as a result, remains misunderstood; for his reaction, he is rejected or attempts are made to «change» or control him.
It is also still not fully understood why some children develop borderline personality disorder, either PTSD or depression, while others do not, as a result of exposure to traumatic events. What makes us resilient or vulnerable?
In search of an answer to this question, a group of researchers led by Martin Teicher studied subjects who experienced something really bad in childhood, but who grew up into mentally healthy adults. It turned out that, in general, their brain is very similar to the brain of patients with diagnoses, with the exception of the amygdala, which is different.
Another interesting point. Bohus and colleagues studied women who had been sexually abused at a young age. It turned out that those of them, whose traumatic experience was not devalued by others, but provided support, were able to subsequently build healthy relationships with partners, while the rest developed certain disorders.
So Anna believes that the root of her problems is the lack of support from her parents: “I don’t love myself, because I was told all my childhood that I was unworthy of love.” And this alone, by the way, in itself draws on trauma — and, perhaps, can lead to the formation of borderline personality disorder.
BREAK THE VICIOUS CIRCLE
But there is definitely light at the end of the tunnel: right now, several groups of researchers are working to develop an approach that will focus on trauma when working with patients with borderline personality disorder. At the moment, the most progressive specialists are already combining the dialectical-behavioral approach with trauma-focused therapy.
One of the main goals of this approach is to help patients connect past traumatic events with what they are experiencing in the present.
“The challenge is to make the brain believe that certain stimuli are no longer a threat,” Bohus explains. “With DBT, we teach patients to recognize, name and regulate their emotions, and therefore control their behavior.” This approach has already proved to be effective. Bohus’ team is now modifying the approach to work with patients without a history of trauma with a capital T.
After spending several months in the clinic, Anna switched to outpatient treatment. She has not fully worked through old traumas, but she copes with her emotions much better. In a sense, she was very lucky: despite everything she had experienced, she was able to find careful and experienced doctors who helped her.
And this is perhaps the main lesson to learn from this whole story: no matter what your past was, how difficult it is for you now, and what diagnosis is on your medical record, never settle for a dismissive attitude towards yourself. Including doctors.