Once upon a time there was a little girl. She was born in the usual way. She was the youngest of four children and lived in a remote community in Northern Manitoba. Her parents struggled financially and carried the wounds of residential school. They often used alcohol to cope. Shortly into the life of this young girl, her father, whom she loved dearly, and who loved her, began to sexually abuse her. At the age of 13, this young girl became pregnant. She was unsure who the father was. Child and family services took this girls’ baby and herself and placed them in care. Over the next three years, this girl was placed in numerous foster homes, and had experienced physical, emotional and sexual abuse on many occasions and sometimes for extended periods of time. Soon this girl became a woman, and by this time she had become addicted to crack. This girl was known to be highly aggressive, and fought with other women and with police who intervened. She hurt herself as well and had multiple suicide attempts. She had been trading sex for housing, food, and protection, and it was no large step to trade it for cash or drugs. During occasional hospital stays, doctors and nurses put warnings on her chart about her history of aggression, and she accumulated numerous diagnosis including anxiety, aggression, depression, and borderline personality disorder. Nowhere on the file were the phrases, “trauma” “complex trauma” “inter-generational trauma” or “residential school effects.” Nowhere on the file were the words “survivor” or “victim.” Discussions between mental health professionals included phrases such as “manipulative,” “gamey,” “dys-regulated,” “aggressive,” “escalated,” “baseline of suicidality,” “at risk,” and “frequent flyer.” Never did they include words such as “precious,” “wounded,” or “normal.”
This girl has been a friend of mine, a roommate, an acquaintance, a client, a news story, and a statistic. I have met her in many places. She lives in the files of many of the people I’ve seen within the mental health system and in many shelters, rooming houses, government housing, rental units, family homes, and on the streets of my city.
Borderline Personality Disorder, or BPD, is a mental health diagnosis that has been around since the publication of the Diagnostic Statistical Manual of psychiatric disorders, DSM III, back in 1980. At that time, the DSM II, which had previously been a thin little book that was relatively unknown, and used only by psychiatrists, was greatly enhanced and expanded. The new version became quickly popular due to its easy to use structure. Mental health clinicians, psychiatric nurses, social workers, and general practitioners began to study and use it on a daily basis to diagnose clients and patients. In 2013, the DSM 5 was in progress and discussions about the “Cluster B personality disorders,” which include Borderline Personality Disorder (BPD), noted the high numbers of women being diagnosed with this disorder and the stigma attached to this particular diagnosis. Debates about removing it from the DSM 5, ensued. Alas, it was not removed.
Judith Lewis Herman, an American physician who specializes in trauma, speaks about the history of societal response to women’s experience of trauma, particularly childhood sexual abuse.
- She speaks about early mythology about demons impregnating girls and women and resulting in ‘demon babies’ who were killed at birth.
- She speaks about Freud’s discovery of rampant childhood sexual abuse and incest among his well to do clients.
- She describes Freud’s subsequent denial of this reality after facing pressure from his colleagues. Freud then chose to describe the trauma symptoms experienced by his clients “hysteria.”
Symptoms of ‘hysteria’ varied widely, and included emotional outbursts, fainting, insomnia, and various physical (somatic) complaints. Patients with hysteria were considered irrational (but then again, so were all women, at that time). Descriptions of incest were attributed to the client’s own longed-for fantasies. Dr’s had, for many years, blamed the pathological ”wandering uterus” for this disorder. With a diagnosis of hysteria, the social pathologies of childhood sexual abuse and incest, nevermind the general mistreatment of women in everyday life, could be ignored and denied. The woman’s symptoms were attributed to her own pathological biology.
Recent studies about the effects of trauma on the body, the personality, the mind, and the emotions, have shown that childhood sexual abuse, prolonged emotional or psychological abuse, or physical abuse, can result in severe disruptions in each of these systems. These are a description of just some of the effects of trauma on an individual:
The body, after living in prolonged states of fear, can lose its’ ability to regulate or calm itself. Or, if this fear occurs early in life, it may not develop the ability to regulate the flow of adrenalin.
Disruptions in identity occur when psychological , emotional, sexual or physical abuse occurs, and is markedly worse when the abuse is prolonged. (See “7 Ways to Love a Volcano” for definitions of emotional and psychological abuse).
Difficulty in emotional regulation can result in severe depression, suicidality, and conflict within interpersonal relationships.
“Many abused children cling to the hope that growing up will bring escape and freedom. But the personality formed in the environment of coercive control is not well adapted to adult life. The survivor is left with fundamental problems in basic trust, autonomy, and initiative. She approaches the task of early adulthood ――establishing independence and intimacy――burdened by major impairments in self-care, in cognition and in memory, in identity, and in the capacity to form stable relationships. She is still a prisoner of her childhood; attempting to create a new life, she reencounters the trauma.”
“Over time, as most people fail the survivor’s exacting test of trustworthiness, she tends to withdraw from relationships. The isolation of the survivor thus persists even after she is free.”
“After a traumatic experience, the human system of self-preservation seems to go onto permanent alert, as if the danger might return at any moment.”
Many, if not most, individuals diagnosed with Borderline Personality Disorder have histories of abuse or trauma. BPD diagnostic criteria, based on DSM V, is characterized by:
“A pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self – mutilating behaviour covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationship characterized
by alternating between extremes of idealization and devaluation.
3.Identity disturbance: markedly and persistently unstable self-image or sense of self
4.Impulsivity in at least two areas that are potentially self-damaging (e.g.,spending, sex, substance abuse, reckless driving, binge eating). Note:Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
5.Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6.Affective instability due to a marked reactivity of mood (e.g.,intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7.Chronic feelings of emptiness.
8.Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).
9.Transient, stress-related paranoid ideation or severe dissociative symptoms.”
(The above criteria can be found at innersolustion.ca/ Diagnostic Criteria for BPD-DSM V)
There is no exclusion criteria (the things that might make you ineligible for a BPD diagnosis) such as experiences of abuse or trauma. Abuse and trauma are generally considered common experiences of people suffering from BPD.
The problem with the way the diagnosis of BPD is being applied today, is that the individuals’ experience of trauma is often minimized or ignored.
When the symptoms become the focus, and the underlying reason for the symptoms are minimized or ignored, individuals who are suffering are sometimes treated as if they are the cause of their own symptoms. Behavioral modification strategies might be used against them (See “Too Many Carrots & Sticks”.) This response to women who suffer the effects of trauma result, at best, in the individual being left without help or reprieve. At worst, she is further penalized and shamed. The personality identifiers described in the diagnostic criteria for BPD, may be entrenched, particularly if the trauma was experienced at a young age, but this is not a sign that these symptoms are “just the way she is.” In fact, they are an reasonable response to what she has experienced.
I believe there are two changes to diagnosis of individuals who experience the effects of trauma which would improve chances of accessing appropriate treatment:
- If the definition of trauma was broadened to include, not only physical or sexual violence, but also prolonged emotional or psychological abuse, particularly in childhood (this might look like a diagnosis of ‘complex trauma’ and and/or of ‘inter-generational trauma’ which might include concepts such as ‘residential school effects’), then individuals who experienced these other types of trauma might be provided treatment appropriate to their experiences of trauma.
- If the symptoms describing Borderline Personality Disorder in the DSM 5 indicated the connection to traumatic experiences, then assumptions about inherent personality traits and the shaming of trauma responses might be reduced.
A BPD diagnosis has potential to be very beneficial to individuals, improving quality of life substantially, if it is used to point mental health professionals towards providing effective treatment options. If stigma is not applied and, if womens’ experience of trauma is not ignored, or minimized, as it has been for centuries.
Judith Lewis Herman speaks about recovery from trauma involving the return of power to the individual. She notes that trauma comes, in large part, due to a feeling of helplessness experienced by the individual who is attacked, abused, or mistreated. In treatment, a therapist or mental health professional can provide her with the tools to manage her anxiety and trauma symptoms, to work on interpersonal communication skills, and to communicate the hope and confidence that she will recover. She may find that she is able to access her own power and autonomy and, in that, find healing and health.
In Winnipeg, there is a resource centre for women who have experienced trauma, particularly childhood abuse, as well as a private trauma clinic. Individual counsellors use various therapies such as Eye Movement Desensitization Reprocessing and Dialectical Behavioural Therapy (DBT) (See “When YOU are the Volcano – 7 Ways to Care for Yourself“). DBT has been proven to be very effective in treating the symptoms associated with BPD. DBT teaches somatic quieting through mindfulness, interpersonal communication skills, and uses aspects of cognitive behavioural therapy to address cognitive distortions.
Men are also diagnosed with BPD, though in lower numbers. Mens’ experience of trauma has a few distinctive features, and men’s expression of the symptoms of trauma may also be different. See Men & Trauma for more about this topic.
For information about Men and Trauma See Men & Trauma- Anxiety, Anger, & Addiction.
For more about the Diagnostic Statistical Manual (DSM) and Mental Health Diagnosis see “Saving Normal”
For more about emotional dys-regulation see” When YOU are the Volcano – 7 Ways to Care for yourself.”
For more about anxiety and panic see “A Good Time to Panic.”