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Let’s get rid of the term ‘borderline personality disorder’

The psychological diagnosis of Borderline Personality Disorder (or BDP) continues to be one of the more heavily debated of the psychological disorders.  The straight-up truth, however, is that it’s a full on pejorative label with stigma that all too often causes clinicians to view borderline clients in a negative and resentful fashion.  The significant majority of people identified as borderline are women and the diagnostic criteria reflects a largely male-oriented ideas of healthy psychological functioning.

It can be true that psychotherapy with borderline clients can often be extremely difficult and arduous and it is not uncommon for therapists to feel exhausted and manipulated by their borderline clients.  Although I feel that the specific ways in which BPD is conceptualized and understood often contributes to this negative outlook.

Psychological theorists, such as Judith Herman, Basil Van der Kolk  and many others, argue that BDP is often better understood as a ‘complex’ form of posttraumatic stress disorder (PTSD). Complex PTSD is a more pervasive and ingrained form of chronic difficulties with stress and anxiety that stem from significant experiences of trauma.  Many of the symptoms entailed in complex PTSD can look very similar to the clinical presentation of BDP.

The idea of seeing BPD as a complex form of PTSD is supported by multiple research findings that have found that a significantly high percentage of people diagnosed with BPD have histories of being victims of substantial traumas (Courtois, 2009; Van der Kolk et al., 2006; Driessen et al., 2000; Zanarini et al., 1997; Ogata et al., 1990).

A study reported by Zanarini et al. (1997), for example, looked a large sample of individuals diagnosed with BPD and found that a significant majority of these people had experiences with sexual abuse at some point during their childhoods. Based on these results, and the results of additional studies, Zanirini and her colleagues concluded that severe experiences of trauma appear to be a substantial etiological factor in most cases of BPD.

Judith Herman (1997) notes that identifying someone as being the victim of a trauma tends to elicit a more sympathetic reaction from psychotherapists and other mental healthcare providers. That is to say, a therapist who sees her client as having trauma-related difficulties is less likely to feel annoyed and resentful toward the client as opposed one who is identified as borderline. Complex PTSD is simply a more compassionate diagnosis… one that fosters a greater degree of understanding and empathy (factors that are often essential if a treatment is going to be effective).

Research reported by Courtois et al. (2009) and Van der Kolk et al. (2006) found that treatments that are based on a primary diagnosis of Complex PTSD are substantially more effective and successful compared to those based upon a primary diagnosis of BPD.  Considering that these two diagnostic labels essentially refer to the same condition, it would appear that the therapist’s perspective, compassion, and understanding concerning the root cause of psychological difficulties might often be a key factor in determining a treatment’s ability to succeed and bring about positive results.

Of course there are plenty of people in the professional community who argue against this whole idea, who reject the notion of re-conceptualizing BDP as a complex form of PTSD.  And many would site the neurological evidence gathered that suggests BPD is a largely organic condition caused by subtle neurological abnormalities that lead to greater sensitivity and vulnerability to negative affect.  This idea is largely supported by functional MRI scans that demonstrate significant alterations in the brain scans of subjects identified with BPD versus neurotypical controls.

These opponents argue that the high rates of histories of trauma among those identified with BPD is merely a co-morbid correlation.  Some have even gone so far as to suggest that the increased prevalence of histories of childhood sexual abuse in BPD may itself be a result of these neurological factors. The argument here is that the reduced abilities for impulse control and social inhibition acts as a factor that increase the likelihood that a specific child will be a victim of sexual abuse (Siever, 1997; Siever et al., 1998).  

Yes, you read that right…  These guys actually came up with a neurological version of blaming the victim.  It’s deplorable and the kind of arcane thinking that makes us headshrinkers look like assholes.   

What I feel these arguments fail to take into account, however, is the fact that the brain is a much more plastic and dynamic organ than many give it credit for.  Neurological structures are just as likely to be shaped and affected by our experiences as the other way around.  More current research has shown similar structural abnormalities among combat veterans diagnosed with PTSD.  This shows that traumatic experiences can impact on the functioning and even the structural anatomy of the brain. 

And the heightened sensitivity in limbic regions of those identified with PTSD are not all that different compared to similar findings among patients identified with BPD.

Now of course the real problem with re-conceptualizing BPD as complex PTSD is that there are many people diagnosed with BPD who do not have histories of significant abuse and trauma (Zlotnick et al., 2003). When considering this factor, however, it is important to keep in mind that what constitutes a psychological trauma can be an extremely relative and subjective matter.  Physical and sexual abuse is clearly traumatic and it can be easy to understand how such experiences might impact on psychological functioning. Other instances of trauma, however, can be much more subtle and covert, yet nonetheless be just as psychologically damaging.

In my own research (Goldblatt et al., 2003), my colleagues and I found that children who were neglected and who were separated from primary attachment figures were indistinguishable from children who had experienced severe physical and/or sexual abuse on a number of empirical rating scales. 

These results, coupled with the results of similar studies (Bradley, 2000; Salzman et al., 1997; Van der Kolk, 1994) indicate that neglect and attachment difficulties can be just as traumatic and psychologically damaging as childhood experiences of sexual and/or physical abuse.

What this indicates is that people diagnosed with BPD who do not have histories of severe childhood trauma may still be understood as possibly experiencing a complex form of PTSD.

With the publication of the new Diagnostic and Statistical Manual of Mental Disorders (the DSM-5), Complex PTSD has been recognized as an official diagnostic label.  Unfortunately, the research has found that the inclusion of this disorder has not correlated with a reduction of cases where patients are identified as BPD.  There are a number of factors that may be contributing to this finding… not the least of which being that, as a new diagnosis, clinicians might shy away from utilizing Complex PTDS for worries that insurance providers will reject reimbursement claims.  

Hopefully things will change soon and we will see less and less cases of BPD.  We’ll see…

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