Why are complex trauma and dissociation relevant in the understanding and treatment of Borderline Personality Disorder

Last year, I was invited to speak at 9th Annual Treatment of Personality Disorders Conference at the University of Wollongong, Sydney, New South Wales (NSW), Australia. The conference was organized by Project Air, a Personality Disorders Strategy that aims to enhance treatment options for people with Personality Disorders, their families and caregivers. Project Air Strategy for Personality Disorders is a partnership between the Illawarra Health and Medical Research Institute at the University of Wollongong and the NSW Ministry for Health and Local NSW Health Districts. It seeks to engage the community, families, and other carers, consumers and health and drug and alcohol services and agencies, in order to support better treatments for personality disorders.

Professor Brin Grenyer, one of the organizers of the conference, asked me to describe three things I learnt from working with complex trauma and that could be interesting to keep it in mind when treating people with Borderline Personality Disorder. As I started thinking, I came up with a list of things that I thought could be interesting to share with readers.

Understanding out of proportion reactions and their link to trauma. Identifying triggers

1. Many psychological problems are mainly caused by the cumulative effect of attachment disruptions, adverse experiences, and unresolved traumatic experiences. Therefore, it is important to explore the experiences that influenced how the person developed the behaviour or symptom.
2. Understanding the apparently out of proportion reactions is crucial. Most of these reactions make complete sense if we are familiar with the client´s trauma history.
3. Impulsive reactions are generally conditioned responses to previous, unresolved trauma. These reactions will not seem as impulsive if we understand the triggers. By understanding triggers, we can work with the issues that are generating apparently impulsive reactions in the here and now.
4. Unresolved experiences function as triggers that evoke reactions to apparently neutral stimuli in the here and now. Triggers can be related to internal experiences and to external cues. When unresolved experiences are reactivated, they serve as triggers. There is a kind of circularity in that unresolved experiences trigger unresolved trauma and old coping mechanisms.
5. Triggers are related to deeply embodied visceral experiences, particularly in relation to painful experiences and memories. For example, a client becomes very suspicious due to a gesture from the therapist that reminds the client of a person who hurt her; or she feels overwhelmed when unresolved abandonment experiences get triggered by the lack of presence of relevant others (or someone arriving late to meet with them).

Internal conflict and lack of integration

1. Lack of integration of the personality is present in Borderline Personality Disorder. This lack of integration manifests in internal conflicts between parts. Traumatic experiences generate dissociative responses, but dissociation (and therefore these responses) is maintained due to internal conflict, lack of integration, lack of realization, and lack of social support (Van der Hart, Nijenhuis, & Steele, 2006). Understanding these aspects is crucial for case conceptualization and treatment planning.
2. The concept of dissociative phobias, that is, phobias that maintain the dissociation of the personality (Van der Hart, Nijenhuis, & Steele, 2006), is crucial in the work of clients with Borderline Personality Disorder and complex traumatization.
3. In some clients the internal conflict can be manifested through arguing or critical voices, which are sometimes confused with psychotic symptoms. Voices can be understood and treated as parts of the personality. Clients need to learn to understand their voices and to communicate in new, more constructive ways. Approaching the conflict with curiosity and compassion leads to understanding and is essential to overcoming dissociative phobias and working towards integration.
4. By identifying the internal conflicts and understanding their links to how relationships to significant others were established, clinicians can adapt interventions to the client´s needs. By understanding the client’s internal working models or schemas and the dissociative phobias that manifest in different moments of treatment, the clinician can have better insight into helping the client deal with internal conflicts. This allows clinicians to structure the work and safely adapt to the client´s pace.

Internalization of messages

1. If the internal experiences of a child–particularly emotions–are not recognized by a caregiver (or are punished), the child will learn to imitate and internalize the negative attitudes of the adult. These attitudes will manifest in the future adult who will repeat the messages he or she learned.
2. Core maladaptive cognitions are frequently internalized negative messages from abusive figures. This explains why they are so entrenched and difficult to change. Clients often continue to look at themselves through the eyes of the abuser many years after the abuse has ended.
3. When clients hear critical voices, the messages are very similar to things they were told as they grew up (in a direct or indirect way). Voices tend to repeat what they have learned. This is related to the work mentioned in the previous section.
4. A fragile identity usually goes hand in hand with these cognitions. When clients have not had the experience of being looked at with love and acceptance, identity is deeply affected and shame becomes a major dynamic. It is difficult for clients to change the way they see themselves without first working to repair the attachment system. 

Lack of regulation and the link to adverse attachment experiences

1. Children learn to recognize their internal states when they have a mirror, an attuned caregiver, who reflects, explains, and responds to them (Siegel, 2010). If what the mirror shows is discordant with what the child is feeling, or if there is no reflection, the inner world will not evolve toward emotional self-regulation. This will persist through adulthood.
2. The inability to self-regulate makes complete sense when we understand that the client received very poor affect regulation from caregivers, such as when needs were ignored or shamed. Shame is the experience of one´s felt sense of self disintegrating in relation to a dysregulating other (DeYoung, 2015).

Expanding the concept of trauma

1. The concept of trauma continues to be interpreted as all-or-nothing. For many professionals, patients, and family members, the word “trauma” is only equal to “sexual or physical abuse”. The concept of trauma is much broader and, at times, much more subtle. In childhood, many perceived threats stem from the caretaker’s affective signals and lack of availability (more than from the actual level of physical danger or risk for survival). These “hidden traumas” are related to the caretaker’s inability to modulate affective dysregulation (Lyons-Ruth & Spielman, 2004).
2. Many people call an event “trauma”, not considering whether or not the subjective experience is a potentially traumatizing event. They forget that the metaphor of trauma pertains to the subjective experience and responses during or after a potentially traumatizing event. On the other hand, over-inclusion can also be a problem: any upsetting event is then labelled as “traumatic” and the word loses its power or significance.

Complex traumatization

1. Borderline symptoms are similar to the commonly known consequences of early, severe, and chronic traumatization. Various experts have proposed that borderline symptoms be classified as disorders of stress: disorders of extreme stress (DESNOS: Van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005), also known as complex posttraumatic stress disorder (Herman, 1992), and posttraumatic personality disorder (Classen et al., 2006).

Dissociation

1. Dissociative symptoms are common in BPD, including memory loss (amnesia) for certain time periods, events, and people, a sense of being detached from the self, depersonalization, derealization, perception of people and things as distorted and unreal, blurred sense of identity, and hearing voices (which stem from various dissociative parts of the personality).
2. Studies on the relationship between BPD and dissociation indicate that pathological dissociation – which I understand to be a manifestation of the dissociation of the personality – correlates with a wide range of indicators of severity and impairment in BPD and complicates response to psychotherapy (Chlebowski & Gregory, 2012; Kliendienst et al. 2011; Yen et al., 2009).
3. A body of research has indicated that dissociative disorders are, in fact, common in BPD (Conklin & Westen, 2005; Ross, 2007; Sar et al., 2004, Sar et al., 2006) and, vice versa, BPD is common in dissociative identity disorder (DID) (Ross, 2007; Ellason, Ross & Fuchs, 1995).

Working with the here and now approach does not always work

1. Focusing on here and now issues can be useful to stabilize and as a preparation to the work with traumatic issues  (Mueser et al, 2008, Harned, Jackson & Comtois, 2010, Mosquera, Leeds & Gonzalez, 2014), but this is not enough in many cases. Working with the here and now and avoiding unresolved issues is exactly what the client has learnt to do. Often, they are experts at diverting attention from memories or intrusions that hurt too much (alcohol, drugs, self-harm, sex, binging, and other methods of self-harm and reckless behaviour). All of these “strategies” tend to sedate their emotional pain from the original traumatization. Trauma confrontation is in many cases essential to achieve comprehensive symptom resolution.

Though all of these learning points have been briefly presented, they could, of course, benefit from more in-depth attention.  There is much more to say about each and every one of them. My hope in sharing these ideas is that they may inspire other colleagues to share those learning points that are important for them.

References

Chlebowski, S.M., & Gregory, R.J. (2012). Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy. American Journal of Psychotherapy, 66, 165-180.

Classen, C., Pain, C., Field, N., & Woods, P. (2006). Posttraumatic personality disorder: A reformulation of the complex posttraumatic stress disorder and borderline personality disorder. Psychiatric Clinics of North America, 29, 87-112.

Conklin, C.Z., & Westen, D. (2005). Borderline personality disorder in clinical practice. American Journal of Psychiatry, 62, 867-875.

DeYoung, P.A. (2015). Understanding and treating chronic shame: A relational/neurobiological approach. New York: Routledge.

Ellason, J.W., Ross, C.A. & Fuchs, D.L. (1996). Lifetime Axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry, 59, 255-267.

Harned, M. S., Jackson, S. C., Comtois, K. A., & Linehan, M. M. (2010). Dialectical behavior therapy as a precursor to PTSD treatment for suicidal and/or self-injuring women with borderline personality disorder. Journal of Traumatic Stress, 23(4), 421-9. doi:10.1002/jts.20553

Herman, J.L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377–391.

Kliendienst, N., Limberger, M.F., Ebner-Priemer, U.W., Kiebel-Mauchnik, J., Dyer, A., Berger, M., … Bohus, M. (2011). Dissociation predicts poor response to dialectical behavior therapy in female patients with borderline personality disorder. Journal of Personality Disorders, 25, 432-437.

Lyons-Ruth, K. & Spielman, E. (2004). Disorganized infant attachment strategies and helpless-fearful profiles of parenting: integrating attachment research with clinical intervention. Infant Mental Health Journal, 25(4), 318-335. PMID: 17464363.

Mosquera, D. (2008). Self-harm: The language of pain (La autolesión: El lenguaje del dolor). Madrid: Ediciones Pléyades.

Mosquera, D. (2015). Rough diamonds: A glimpse into Borderline Personality Disorder. Charleston: Createspace Independent Publishing Platform.

Mosquera, D., Leeds, A. & Gonzalez, A. (2014) Application of EMDR therapy to Borderline Personality Disorder. Journal of EMDR, Practice and Research, 8(2): 74-89. doi:10.1891/1933-3196.8.2.1

Mosquera, D., Gonzalez, A., & Van der Hart, O. (2011). Borderline personality disorder, childhood trauma and structural dissociation of the personality. Revista Persona, 11(1), 44-73.

Ross, C. A. (2007). Borderline personality disorder and dissociation. Journal of Trauma and Dissociation, 8(1), 71-80.

Mueser, K. T., Rosenberg, S. D., Xie, H., Jankowski, M. K., Bolton, E. E., Lu, W., . . . Wolfe, R. (2008). A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 76(2), 259-71. doi:10.1037/0022-006X.76.2.259

Sar, V., Akyüz, G., Kundakçi, T., Kiziltan, E., & Dogan, O. (2004). Childhood trauma, dissociation and psychiatric comorbidity in patients with conversion disorder. American Journal of Psychiatry, 161, 2271-2276.

Sar, V., Akyüz, G., Kugu, N., Öztürk, E., & Ertem-Vehid, H. (2006). Axis I dissociative disorder comorbidity in borderline personality disorder and reports of childhood trauma. Journal of Clinical Psychiatry, 67, 1583-1590.

Siegel, D. (2010). Mindsight. Bantam Books: New York, 2010; Oneworld Publications: Oxford, 2010

Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: Norton.

Van der Kolk, B., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389–399.

Yen, S., Johnson, J., Costello, E., & Simpson, E.B. (2009). A 5 day dialectical behaviour therapy partial hospital program for women with borderline personality disorder: Predictors of outcome from a 3-month follow-up study. Journal of Psychiatric Practice, 15, 173-182.