Borderline: consequence of interpersonal traumas in childhood

Borderline personality disorder : living with a thin skin

The disturbing dreams began two years ago. Ann was hospitalized for burnout. In dreams, she saw her father, saw scenes of physical and psychological abuse. It was flashbacks to her childhood.

Ann is actually not called Ann, her name is changed for her protection. She has three daughters and is a single parent. She spent her childhood in an East German town an hour’s drive from Berlin. Her father and grandfather were alcoholics. She was often alone at home after school, but it was even worse when her parents came home. They were both violent, physically and mentally. As a teenager she was raped several times. A close friend of hers was murdered by her own father when she was pregnant.

What the now 40-year-old suffers most is how little her parents cared about her. When told she had been raped, her mother said it was her own fault. When she was once hit by a car, her father said pitilessly, "Get up again, it’s all right." It wasn’t until a colleague at work asked in shock why her head was covered in blood that she realized how horrific the accident had been. "That’s the worst part for me," Ann says as her voice begins to shake and tears well up in her eyes. "Having parents who don’t see me as a person."

Sometimes she wakes up in the morning with bloody arms

Ann recalls being an angry, aggressive child and having difficulty controlling her emotions and communicating with others. As a teenager she attempted suicide twice. As an adult, she sought risk, drove too fast and often felt the need to hurt herself, slashed her skin. Sometimes she would wake up in the morning with bloody arms. Dealing with their feelings continues to be one of their greatest difficulties. When problems arise, she is quickly overwhelmed: "I have to talk to someone right away," she says, "otherwise I’m afraid I’ll hurt myself."

I meet Ann at the Central Institute of Mental Health (ZI), which spans several city blocks in the center of Mannheim, Germany. There treated for complex post-traumatic stress disorder (PTSD) – severe symptoms that follow prolonged trauma – as well as borderline personality disorder (BPD), characterized by intense, unstable emotions, a negative self-image, and relationship problems, often including self-injury and suicidal ideation.

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BPD and complex PTSD have some things in common, such as problems with emotion regulation and self-image. A key difference, however, is that complex PTSD is described as a response to trauma, but BPD is not. Many people meet the criteria for both disorders. The extent to which trauma plays a role in BPD, however, is the subject of intense debate in psychiatry and psychology.

Studies show that between 30 and 80 percent of people with BPD meet criteria for a trauma-related disorder or report past trauma-related experiences. According to most clinical professionals who have examined or treated people with BPD, not everyone diagnosed with the disorder has experienced trauma – at least not in the traditional way. However, there is growing evidence that "trauma" is not clearly definable: even when stressful experiences don’t fit the textbook definition, they can leave lasting marks on the brain and increase the risk for developing mental health disorders like BPD.

These findings challenge the definition and treatment of BPD. Some professionals and sufferers are calling for BPD to be renamed complex PTSD. They argue that the overlap is large enough. BPD has long been heavily stigmatized – even by professionals. Affected patients are considered manipulative, difficult, and resistant to treatment. Others believe that while not all BPD is complex PTSD. But there is enough evidence that early stressors play a role in the development of BPD to rename the disorder, he said.

"I don’t think borderline personality disorder fits into the concept of personality disorder," says Martin Bohus, a psychiatrist at ZI. "It fits much better with stress-related disorders, because we know that there is no borderline disorder without severe early interpersonal stresses."

When Bohus did his medical internship on a psychiatric ward, he saw a patient sitting on the floor painting herself with blood from self-inflicted injuries. He inquired about her. The leading psychiatrist only said: "A borderline patient, you can’t do anything about it". Just dismiss them." And what if she commits suicide?, Bohus asked. "They never kill themselves," the psychiatrist replied, "they just say that they will do it." Bohus followed his mentor’s advice and discharged the patient. Shortly thereafter, the woman took her own life.

Bohus is now in his mid-60s and an established psychiatrist. This experience was the first of many that made him realize something was wrong with the way clinicians were treating people with BPD. "At the time, there was an extremely conservative, I would say hostile, paternalistic, patronizing attitude toward clients," Bohus says.

The story of a highly controversial diagnosis

The term "borderline" was coined in the 1930s by German-American psychiatrist Adolph Stern. He thus described a gray area between neurosis – mental suffering such as depression and anxiety, but without hallucinations or delusions – and psychosis, in which people lose touch with reality. These patients, he wrote, are "extremely difficult to treat by any psychotherapeutic method".

For years, "borderline" remained a nebulous term. It wasn’t until the 1970s that it became an official diagnosis. At the time, John Gunderson, a psychiatrist at McLean Hospital in Massachusetts, was studying a group of patients who had been misdiagnosed with schizophrenia. He defined six main characteristics they had in common: intense emotions, typically hostile or depressive; a history of impulsive behavior; brief psychotic experiences; chaotic relationships; illogical or confused thought processes, evident, for example, in bizarre responses on unstructured psychological tests – and the ability to maintain an outward appearance of normalcy.

Shortly thereafter, in 1980, borderline personality disorder found its way into the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the main manual used by psychiatrists and psychologists in the U.S., as well as for research purposes worldwide. There it is one of several different personality disorders. Its hallmarks are characteristic patterns of thought and behavior that deviate from social expectations and cause individual and interpersonal problems.

The diagnosis helped to explore the basis of the disorder and advance treatment methods. Long-term studies by Gunderson and his colleagues also showed that despite the prevailing view that borderline is a chronic, incurable illness, most patients do eventually recover. It is still controversial how borderline relates to other personality disorders.

BPD is more commonly diagnosed in women, but some studies suggest that the proportion is actually about the same in men and women. The difference between the sexes may be due to the fact that women are more likely to seek psychiatric treatment and men are more likely to be diagnosed with narcissistic, antisocial or other personality disorders. Because of this and other overlaps, many experts point out that there is a lack of evidence to support such a distinction. Instead, they advocate for what they call a dimensional model, which provides a single, broad diagnosis of "personality disorder" and characterizes it by the severity of symptoms, among other things.

Other experts argued vehemently against revising the existing system. Among them were Gunderson and Bohus. They argue that the large body of research on specific disorders – particularly BPD – has led to tailored treatments, and a new model would undo that progress and harm patients. The new version of the International Classification of Diseases (ICD), the diagnostic system published by the World Health Organization, adopted a new dimensional model but retained a separate borderline label to reassure supporters of the diagnosis. The DSM, last revised in 2013, retained the categories but also provides a diagnostic framework for the dimensional approach. (Both the DSM and ICD are used worldwide.)

Inconsistencies abound. Some experts, such as Carla Sharp, director of the Laboratory of Developmental Psychopathology at the University of Houston, argue that the features of BPD are not so different from those of the other personality disorders. Others, including Bohus, believe BPD is unique and specifically linked to past traumatic experiences. In contrast, how such events contribute to other personality disorders is unclear. Most personality disorder studies to date have studied people with BPD because they are the most likely to seek help.

Julian Ford, a clinical psychologist at the University of Connecticut School of Medicine, believes trauma is a possible cause of all personality disorders. "There is enough research to suggest that trauma can play a role in virtually any personality disorder," Ford says. "Exactly what that role is – I don’t know that we have the research to determine that."

One-time borderline therapy: "descent into hell"

Bohus recalls his early years as a psychiatrist at Weill Cornell Hospital in White Plains, New York. There he was confronted with two radically different methods of treating BPD. In one, patients were confined to a locked ward and treated with powerful medications. The climate around her was hostile and distrustful, and most stayed for a year or more. In the other, the department was open, the atmosphere warm and supportive. Patients were encouraged to help each other develop skills that enabled them to endure their distress. Most were noticeably better after a few months and were able to leave the facility.

The latter department operated according to a method developed by U.S. psychologist Marsha Linehan, who had herself been diagnosed with BPD. Shortly before she graduated from high school, she was placed in a locked ward of a psychiatric hospital in Hartford, Connor. There, Linehan cut her limbs with sharp objects, burned herself with cigarettes and banged her head on the hospital floor. Her doctors applied a range of treatments, including medication, electric shocks, isolation and cold therapy (in which she was wrapped in cold blankets and strapped to a bed).

Linehan describes this time in her memoir as a "descent into hell". But her own experience motivated her to dedicate her life to helping others with the disorder. It identified dysregulation of emotions as the driving force of the disorder: people with BPD constantly experienced a roller coaster of emotions. "Borderline patients are the psychological equivalent of third-degree burn patients," Linehan told Time magazine in 2009. "They don’t have an emotional skin, so to speak. Even the slightest touch or movement could cause them immeasurable suffering."Seemingly insignificant provocations could trigger extreme anger, shame or despair in them.

On this basis, Linehan developed a new treatment she called dialectical-behavioral therapy (DBT). The name "dialectical" describes the balance between acceptance and change: accepting oneself and changing harmful behavior. Clinical studies have shown that DBT reduces some of the symptoms such as self-injury, suicidal behavior and hospitalizations.

When Bohus experienced DBT in practice, he recognized that it was far superior to the other methods available at the time for treating BPD. After returning to Germany, he founded the country’s first facility specializing in the treatment of BPD with DBT. Since then, DBT clinics have become widespread in Europe and the U.S., and have also been established in Latin America, Asia and the Middle East. Despite the benefits of DBT, however, Bohus found over the years that it had its limitations in treating a problem that many of his patients experienced: traumatization.

Even many small traumas have a lingering effect

Post-traumatic stress disorder (PTSD) was added to the DSM as an official diagnosis in 1980, making it the first mental illness defined by an external cause. It described a state in which problems such as flashbacks, nightmares, and anxiety occur after a horrific event. Ailments similar to the shell shock described in World War I had been known for decades. But it was the awareness of the psychological needs of Vietnam War veterans that provided the decisive impetus.

In the early 1990s, Judith Herman, a psychiatrist at Harvard University, proposed the diagnosis of "complex PTSD" after reviewing the literature on trauma survivors. It was meant to describe a set of symptoms that result from long-term exposure to extreme stress. These problems, Herman said, occurred when one person was under the control of another, such as in prisons, labor camps, or in some families. These included difficulties with emotion regulation, unstable relationships, pathological changes in identity and self-image, and self-destructive behavior.

"The current formulation of the PTSD diagnosis derives primarily from observations of survivors of relatively limited traumatic events," Herman wrote in a 1992 essay. "It does not capture the multiple consequences of long-lasting, repeated trauma."The symptoms of people with complex PTSD could be "too easily attributed to character issues" and misdiagnosed as a personality disorder.

Decades of debate followed. One of the major sticking points is the significant overlap between this diagnosis and BPD. Lois Choi-Kain, a psychiatrist and director of McLean Hospital’s Gunderson Personality Disorders Institute, recalls the heated arguments in the early 2000s. "There was a great divide and an almost raging controversy about the distinction between BPD and PTSD or trauma-related disorders, as if they were mutually exclusive and as if only one could exist," Choi-Kain says. She speaks of two camps: those who thought PTSD was wrongly pathologized as a personality disorder, and others who found that many people with BPD had experienced trauma in their past, but that this did not explain the entire disorder.

A key question at the heart of this debate was what counts as trauma? Although some people with BPD have had severe traumatic experiences and clearly fit the complex PTSD diagnosis, many sufferers do not.

One of them is 49-year-old Rebbie Ratner, who was diagnosed with BPD a decade ago. She runs the YouTube channel BorderlineNotes to raise awareness of the condition. Ratner has long sought an explanation for her emotional pain and a host of other problems, including many failed relationships and a severe eating disorder. She had also considered a diagnosis of complex PTSD. "It never quite convinced me," Ratner says. "Some really psychologically difficult things have happened in my family," she adds. But none of it, they say, was severe enough to meet the criteria for a trauma-related disorder. "I think I have parents who really love me."

In the fifth (and most recent) edition of the DSM, the term trauma includes, first, events in which a person is self-inflicted and directly exposed to death, serious injury, or sexual violence. Second, it may witness, for example, repeated exposure to such events at work, or learn that such an event has happened to a close person.

For many people working in the healthcare sector, however, things are not so clear-cut. The official definition describes trauma "with a capital T" – as opposed to the "small T," the trauma of stressful experiences such as verbal abuse, neglect, bullying and poverty, which are not considered severe enough to be of any consequence. "Defining trauma is always extremely tricky," says Andreas Maercker, a clinical psychologist at the University of Zurich and one of the proponents of complex PTSD.

A large U.S. survey captured potentially traumatic experiences ranging from violence and neglect to growing up in an unstable home. Result: nearly two-thirds of adults have had at least one such experience. Neuroimaging studies show that even multiple small traumas can leave lasting marks on the brain, especially if such stresses are experienced in childhood or adolescence, when the brain is still developing.

Some changes are very specific. For example, people who were scolded by their parents in childhood were found to have changes in the auditory cortex related to language difficulties. Broader effects include a reduced hippocampus (a structure involved in memory and learning), increased activity in the amygdala (an important center for emotion regulation), and disruptions in the connections between these and other brain regions.

"The effects of emotional abuse and emotional neglect are really quite profound," says Martin Teicher, director of the Developmental Biopsychiatry Research Program at McLean Hospital. "They are completely equivalent to physical abuse or sexual abuse in terms of impact on the brain."

Studies of people diagnosed with BPD have brought to light environmental stressors that increase the risk for developing the disease. This includes "major T-trauma" such as childhood sexual abuse and "minor T-trauma" such as harsh parenting, neglect and bullying. Bohus and another psychiatrist at ZI, Christian Schmahl, along with their colleagues, have found that patients with BPD and those with a history of trauma have some neurobiological changes in common. These changes include structural and functional abnormalities in the limbic system, which is associated with emotions and includes the amygdala and hippocampus.

This overlap, Schmahl says, could indicate a trauma or stress signature of BPD. Clearly delineating such a neuronal signature is difficult, but results to date have already opened up new treatment options. Schmahl and his colleagues at ZI are currently testing whether neurofeedback training of the amygdala, which teaches sufferers to control their brain activity in real time, can complement existing therapies.

"Traumatic experiences, whether childhood bullying or neglect by parents or caregivers, have long-term consequences for individuals. They affect his ability to trust others, regulate his emotions and learn to cope," says Shelley McMain, a clinical psychologist at the Centre for Addiction and Mental Health in Toronto. "They have far-reaching consequences in different areas of life." That’s why it’s very important to consider the effects of negative childhood experiences in therapy, he said.

Born with a sensitive temperament

Some professionals, such as Choi-Kain, believe that while stress and past trauma play a large role in the development of borderline personality disorder, the disorder has other components as well. For example, studies of families and of identical and fraternal twins (who share nearly 100 percent and about 50 percent of their genes, respectively) suggest a genetic component. Such biological dispositions can mean a child is born with a sensitive temperament, says Carla Sharp of the University of Houston. This, she said, makes it more likely to find difficult situations distressing.

As Choi-Kain also noted, trauma and BPD are not related in only one way. Borderline symptoms such as emotional dysregulation and sensitivity can interfere with the ability to cope and communicate well, she explains. "A person who is emotionally and interpersonally sensitive becomes impulsive and angry with others when he or she feels hurt or threatened, and is at risk of being misunderstood and experiencing dismissive, retaliatory, or controlling reactions from others." These vulnerabilities may explain why people with the disorder repeatedly face social adversity, Choi-Kain says. In a study of more than 2,000 adolescent girls, the severity of their BPD symptoms predicted how harsh their parents’ parenting was the following year.

That’s why Choi-Kain believes that replacing the diagnosis of BPD with that of complex PTSD could do more harm than good. "A person can develop BPD because they’ve been dealt a very difficult hand, both biologically and on the part of the environment," she says. "And treating people with trauma separately – that’s like saying this disorder is only legitimate if you’ve been severely traumatized."

Trauma caused by devaluation and lack of caring

One of the biggest mysteries is why adverse childhood experiences lead to disorders like BPD, complex PTSD, depression, or substance use in some people – but not in others. In search of answers, Teicher’s team conducted imaging studies of individuals who did not receive a psychiatric diagnosis despite childhood maltreatment. Surprisingly, their brains looked very similar to those of people with a variety of diagnoses – but with differences in certain regions, such as the amygdala. According to Teicher, these differences may explain why some people don’t suffer from psychological aftereffects.

What makes vulnerable, however, remains an open question. Those who later develop BPD may have grown up in what Linehan calls a "traumatically devaluing environment". Examples include a lack of compassion and caring from parents in times of need, constant disapproval from family members, or bullying from peers. If such experiences accumulate, there can be consequences, such as a sense of alienation and particular sensitivity to rejection, Bohus says. "Most of our patients really struggle to accept positive signals, and it’s all because of the experience of repeated traumatic invalidation," he says.

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