Borderline Personality Disorder
Transcription
Borderline Personality Disorder
The Impact of Psychological Trauma on Personality: Borderline Personality Disorder and Complex Trauma Reactions Dr Walter Busuttil Consultant Psychiatrist and Medical Director [email protected] Aims • • • • Define Psychological Trauma Define Complex Trauma Reactions Define Borderline Personality Disorder Define interaction between Personality and Post Traumatic Stress Disorder and other trauma related disorders. PTSD Extreme Traumatic Experience- out of the range of normal experience, perceived with intense fear, horror, helplessness. Three core cluster symptoms: • Re-experiencing • HyperArousal • Avoidance A Dynamic Model for the Interaction of the Symptom Clusters in Established PTSD. Modified by Busuttil (1995) from Horowitz (1976) Information Processing Model Stressor Arousal Re-experiencing Avoidance Simple & Complex PTSD Simple PTSD • Single Trauma • • • • • Complex PTSD Multiple Trauma Traumatised Under age of 26 Developmental stage Attachments Neuro-developmental stage Multiple Traumatisation Considerations: • Nature and Extent of Trauma Personal General • • • • • Age and Developmental Stage Reason / Cause / Ideology Support - Group vs Isolation Sustained - predictable / unpredictable Intermittent Traumatisation in Childhood • Age • Context - act of God / act of Man? • Multiple vs Single • Dose response? • Meaning • Developmental Stage • Brain development • Attachments • Open vs Secret • Individual vs Group • ABUSE: • Physical vs Sexual vs Emotional vs Mixed • Perpetrator / Power, Control, Choice. • Drug induced state • Systematic vs NonSystematic: Organized? Eg Pornographic ring? • Within an institution? DSM-IV Complex PTSD Working Party Study • Multiple traumatisation below the age of 26 years predicted development of Complex PTSD • Exposure to Multiple traumatisation after the age of 26 years did not predict Complex PTSD Complex PTSD DSM-IV Field Trials Adult Survivors of CSA (van der Kolk et al, 1994) Alterations in 7 dimensions: • • • • • • • Affect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation. Attention & concentration: dissociation, amnesia, depersonalization Self-Perception: helplessness, guilt, shame. Perception of perpetrator: idealization of the perpetrator or feelings of vengeance. Relationships with others: isolation, mistrust, victim role, victimization of others Somatisation: GIT; CVS; Chronic pain, conversion etc. Systems of meaning: despair, hopelessness, major changes to previously well held beliefs Disorders of Extreme Stress Not Otherwise Specified (DSM-IV) (DESNOS) (Herman, 1992) • Defined in Adult Survivors of Childhood Sexual Abuse • DESNOS + PTSD = Complex PTSD (1995/6) Complex PTSD: A diagnostic framework- disturbance on three dimensions (Herman, 1992; Bloom, 1997) • Symptoms • Characterological / personality changes • Repetition of Harm Complex PTSD Disturbance on Three Dimensions (after Bloom 1999) • • Symptoms of : PTSD Somatic Affective Dissociation Characterological Changes of: Control: Traumatic Bonding Lens of Fear Relationships: Lens of extremity-attachment versus withdrawal Identity Changes: Self structures Internalized images of stress Malignant sense of self Fragmentation of the self • Repetition of Harm To the self - faulty boundary setting By others - battery, abuse Of others - become abusers Deliberate self harm DSH/Suicidality • History of abuse is a powerful predictor of suicidality, even more than a diagnosis of depression (Read et al, 2001). • CSA victims are more likely, as well to be repeaters of suicidal attempts as compared to PTSD sufferers who did not suffer sexual abuse (Taylor et al, 1994). • Self-harm by cutting is very common among Complex PTSD sufferers & BPD (Busuttil, 2006a; Busuttil, 2006b). Just to clarify: • CPTSD is not a diagnostic category in DSM-IV. • Concept of DESNOS is defined as ‘associated feature’ of PTSD • DESNOS+PTSD =CPTSD Differential Diagnosis - Multiple Traumatisation • Complex PTSD • Borderline Personality Disorder • Dissociative Disorders • Enduring Personality Change After Catastrophic Stress •Psychotic Illnesses: Schizophrenia / Bip Aff Dis Dissociative Disorders • • • • • Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Depersonalization Syndrome Dissociative disorder not otherwise specified • NB: Dissociative symptoms also included in criteria for ASD; PTSD & Somatisation Disorder. An additional Dissociative Disorder diagnosis is not given if the dissociative symptoms occur exclusively within one of these disorders. Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) Prolonged exposure to life threat/s PTSD may precede the disorder features seen after exposure to threat: • a hostile mistrustful attitude towards the world • social withdrawal • feelings of emptiness or hopelessness • chronic feelings of being on edge or threatened • estrangement Childhood Trauma Recent Concepts Developmental Trauma Disorder in children & adolescents: Diagnostic framework criteria: • Exposure • Triggered dysregulation in response to trauma cues • Persistently altered attributions and expectations • Functional Impairment. Borderline Personality Disorder DSM-4 criteria • • • • • • • • • Frantic efforts to avoid real / imagined abandonment Intense unstable interpersonal relationships Identity disturbance Impulsivity - self damaging: driving, sexual, binge eating Suicidal gestures / self mutilation Affective instability Chronic feelings of emptiness Anger: intense / inappropriate / difficulty controlling Transient Paranoid Ideation / Dissociation (stress related) Apart from DSM-IV crtieria consider additional dimensions taken from the Diagnostic Interview with Borderlines-Revised (Zanarini et al, 1989; Zanarini 2005). 1. Affective psychopathology, including • chronic intense dysphoria; • mood reactivity or affective lability. 2. Cognitive psychopathology including • overvalued ideas of worthlessness or guilt, • depersonalization and derealization • non-delusional suspiciousness and ideas of reference. • Quasi-psychotic or psychotic–like symptoms (transient, circumscribed, and reality based delusions and hallucinations) • genuine delusions or hallucinations. 3. Serious Identity Disturbance – frequent shifts in partial identities that are acceptable versus others that are negative. 4. Behavioural Disturbance or Impulsive Behaviour including: • Self-mutilation, • suicidality, • substance misuse, • disordered eating, • promiscuity, • verbal outbursts, • spending sprees, • reckless driving. 5. Interpersonal Psychopathology including, • intense unstable relationships that shift between idealization and devaluation; – frantic efforts to avoid real or imagined abandonment; – devaluation, – manipulation; – demandingness; – entitlement, – treatment regressions; – special relationships; – dependency and counter dependency, – distortions of the truth, – sadomasochistic tendencies Aetiological theories for BPD are unclear. • Early childhood environmental factors - important (Silk et al, 2005). • Psychoanalytical theory: The internal environment of child who goes on to develop BPD is primitive because as a child the person has experienced situations that have either caused developmental arrest or made them regress under stress. • Regression occurs particularly in situations of separation. Attachment Theory (Bowlby, 1979; Fonagy, 2002; Silk et al, 2005). • Early environment of infants - reinforced by the parenting received. • Normal development requires degree of reciprocity in early relationships: develops emotional regulation. • The infant’s experience of various environmental cues results in learning subjective feelings of security or insecurity helps emotional responses and how to maintain sense of homeostasis in difficult situations. • Infant’s experiences with the caregiver become organized into internalized working models of attachment of the self with others. This becomes prototype for the future attachments and relationships. Attachment Theory (Silk et al, 2005). Two patterns of disturbed attachment can occur: 1. Emotional over involvement with a parent, and 2. Role reversal with the parent Gunderson (1996) considers that the BPD patient’s inability to tolerate aloneness and a fear of abandonment has its roots in insecure attachments. Traumatic Exposure • CSA: extremely common in BPD sufferers, rates ranging between 16 to 75% (Silk et al, 2005). • Some workers have linked PTSD with BPD by virtue of the consistent presence of a history of CSA, and see BPD as a residual syndrome that develops after PTSD resolves in childhood. • Others have seen BPD as leading to dissociative disorders in adulthood (Stone, 2005). • While similarities between CPTSD and BPD exist, clear distinctive phenomena have been deduced (Gunderson, 1996; Gunderson & Sabo, 1996). • In PTSD a propensity to self-imposed isolation is very common, whereas BPD patients have intense relationships and fears of abandonment. • Also in CPTSD, PTSD symptoms are present and in some cases of BPD especially in those with a negative history of traumatic exposure, PTSD symptoms are absent (Gunderson, 1996; Gunderson & Sabo, 1996). BUT: • Not all people subjected to repeated trauma in childhood or adulthood develop PTSD or DESNOS. Some of those traumatized in childhood, go on to develop other disorders such as borderline personality disorder or dissociative identity disorder possibly without PTSD. This variability needs to be studied. • family variables such as levels of family support and cohesion may be more predictive of long term effects of abuse than the abuse-specific variables such as the severity or duration of the abuse itself ( Alexander, 1992) • Particular attachment patterns antecedent to the abuse itself may predict how a child responds to an abusive or traumatic experience…. a disorganized/disorientated attachment in which the attachment figure is often the source. • While CSA is associated with severe long-term sequelae, there is no evidence of a specific constellation of symptoms unique to sexual abuse victims. • Flawed attachment organization sensitizes the child to later trauma (Fonagy et al, 2000). This would increase vulnerability to developing PTSD later in life (Chu, 1992; Lauterbach & Varna, 2001). Biological Theories Biological Theories Overlap BPD and PTSD BPD: • Neuro-imaging findings demonstrate that the most consistent structural or functional findings in BPD patients are in frontal and limbic regions (Lyoo, 2005). • The amygdala has a key role in the fear response and emotional processing and is implicated in the aetiology of PTSD as has been discussed earlier. • Stress and traumatic events have been reported to increase cortisol levels and decrease brain neurotrophin factor. • The amygdala and hippocampus are brain areas sensitive to exposure to high levels of cortisol and therefore neurogenesis of these structures may be hampered by the sustained high levels of cortisol (Teicher et al, 2002, 2003; Lyoo, 2005). Biological Theories Overlap BPD and PTSD PTSD: • LIMBIC SYSTEM malfunction: mainly amygdala & hippocampus (van der Kolk, 1996). Supported by PET provocation studies (Pitman, 2000; Shalev, 2001). • PET studies: pre-frontal, limbic and peri-occipital; non-dominant hemisphere narrative centre (Broca’s area) malfunction. • Malfunction of the emotional centres (the limbic system, especially the amygdala); in combination with the malfunction of the narrative centre; reflect respectively, the high emotional loading of the content of the traumatic material, and the difficulty in accurate recall and the ability to construct a coherent trauma narrative. • PET scan findings reflect difficulty patients have when attempting to disclose their traumatic stories coherently (Pitman, 2000; Shalev, 2001; Hull, 2002). Similarities in constructs of BPD and PTSD (John Briere,2002) • PTSD: intrusive feelings, thoughts, and memories triggered by stimulus, often followed by attempts to avoid such triggers or their emotional effects. • Borderline personality disorder: additional problems with identity and self-other boundaries, and often sudden emotional outbursts, self-defeating cognitions, feelings of emptiness and intense dysphoria, and impulsive, tension-reducing behaviour. These are triggered by perceptions of having been abandoned, rejected, or maltreated by another person. • The "borderline" person is often viewed as having problems in impulse control, and as being emotionally over reactive to perceived losses or maltreatment, responding with angry affect and sudden, ill-considered behaviour. A comparative example, (Briere 2002) • A Vietnam veteran with PTSD might have intrusive sensory reexperiences of a combat scenario after being triggered by the sound of a car backfiring, and, upon experiencing the Vietnam era fear associated with the combat memory, engage in attempts to find safety. • An individual with borderline personality disorder, after being triggered by a perceived slight in an intimate relationship, might experience sudden, intrusive thoughts and feelings of abandonment and betrayal associated with childhood maltreatment, and reexperience abuse-era desperation and anger associated with that memory. The individual might then engage in dramatic negative tension-reducing or proximity-seeking behaviour in the context of that relationship. • Both are having posttraumatic reactions that involve reliving a previously traumatic event, although the relational components of the latter are often seen, instead, as evidence of a personality disorder. Diagnosis • Diagnosing CPTSD presents challenges. It must be distinguished from BPD although overlaps exist. – take a trauma history? May not tell you! • Co-morbid psychotic depression or psychoses generated following substance misuse are common. • Schizoaffective disorders, schizophrenia and manic depression need to be considered in a differential diagnosis (Sareen, et al, 2005). DSM-V / ICD-11 • High controversy as to whether separate diagnostic category required for Complex PTSD • Developmental Trauma Disorder in children (DTD) will probably be included - but ? • Personality Disorders category being restructured and may be included under axis 1 • Disorders of affective instability? Or emotional regulation? Treatment of Complex PTSD: basic Principles (Herman 1992) • Stabilization & Safety • Working through of Traumatic material – disclosure – psychotherapy • Rehabilitation Treatment of Borderline PD with or without history of trauma exposure • Stabilization & Safety – SKILLS TRAINING (Dialectic Behaviour Therapy / STEPPS) If trauma has been perpetrated : • Working through of Traumatic material – disclosure – psychotherapy: Trauma Focussed-CBT/Eye Movement Desensitisation and Reprocessing (EMDR) other TF Therapies If no trauma: • CBT/Schema Focussed therapy • Rehabilitation Reading list • Briere & Scott (2006) Principles of Trauma Therapy. A guide to symptoms evaluation and treatment. Thousand Oaks, CA Sage. • johnbriere.com • Briere & Langtree (2008) Integrative treatment of complex trauma for adolescents (ITCT-A). • Busuttil, W. (2009) Complex PTSD: A useful diagnostic frame work? Psychiatry, 8:8, 310-314. • De Zulueta F, (2006) Inducing traumatic attachment in adults with a history of child abuse: forensic applications. Brit J Forensic Practice, 8,(3 )4-15 Recommended reading • Effective treatments for PTSD. ISTSS Practice Guidelines (2009) eds Foa, E Keane & Friedman, M J. Guilford Press: New York. • Innovative Trends in Trauma Treatment Techniques. (2007) (eds M B Williams & J Garrick). Howarth Press: New York, USA. • M Nasser, K Baistow & Treasure J (2007)When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Routledge: London. • Luxenberg, T., Spinazolla, J., Hidalgo, J., Hunt, C. & Van der Kolk, B. (2001). Complex Trauma and Disorders of Extreme Stress (DESNOS) Part Two: Treatment. Directions in Psychiatry, 26, pp. 395-414. • Van der Kolk, B., Roth, S, Pelcovitz, D., Sunday S. & Spinazolla, J. (2005). Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal of Traumatic Stress, 18 (5), pp. 389-399. References • Bloom, S. (1997) Creating Sanctuary. Toward The Evolution Of Sane Societies. London: Routledge, • Briere J & Scott C (2006) Principles of Trauma Therapy, A Guide to Symptoms, Evaluation and Treatment. Thousand Oaks, CA: Sage • Busuttil, W (2006) The development of a 90 day residential program for the treatment of Complex Post Traumatic Stress Disorder. Book Chapter (eds M B Williams & J Garrick ). In Innovative Trends in Trauma Treatment Techniques. Howarth Press: New York, USA. • Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56, (eds M Nasser, K Baistow & J Treasure). Routledge: London. • Cloitre M, Courtois, C., Charuvastra et al, (2011) Treatment of Complex PTSD: Resulta of the ISTSS Expert Clinician Survey on best practices. J Traum Stress 24, 615-627 • Kinniburgh, K.L., Blaustein, M., Spinazzola, J et al (2005) Attachment, self regulation and competency. Psychiatric Annals 35, 424-430. • Sareen, J. Cox, BJ Goodwin, RD et al, (2005) Co-occurrence of Post Trauamtic Stress Disorder in a nationally representative sample. Journal of Traumatic Stress, 18, 313-322 • Zanarini, M. C. (2005) The subsyndromal phenomenology of borderline personality disorder. In Borderline Personality Disorder.(ed M C Zanarini) pp19-40. Taylor Frances Group. London.