When Professor Andrew Channen was a trainee psychiatrist in 1983, people with borderline personality disorder (BPD) who self-harmed were “vilified” and treated “horribly”.
“There was a myth that somehow they were indestructible,” he says. Despite the teacher’s words, “most of them died before the training was over.”
More than 40 years later, Chanen is director of clinical practice and head of personality disorders research at Origen, the national center for youth mental health at the University of Melbourne, and says BPD remains one of the most stigmatized and discriminated against mental health conditions. It states that Disability in Australia and overseas.
overwhelmingly diagnosed in womenBorderline personality disorder is characterized by difficulty managing emotions, rapid mood swings, self-harm, often accompanied by suicidal thoughts, and unstable self-image.
Some Australian clinicians are calling for borderline personality disorder to be recognized as a trauma disorder rather than a personality disorder, arguing that doing so will result in better treatment and outcomes.
Arguments for rethinking BPD
American psychoanalyst Adolf Stern introduced the term “borderline” into psychiatric terminology in 1938. use it to describe patient groups A person who does not fit into the diagnostic categories of neurosis or psychosis.
Some studies have shown that borderline personality disorder is associated with more child abuse and neglect than any other personality disorder, but the rates vary depending on the situation. Maximum 90%, minimum 30%.Ann Analysis of 97 studies They found that 71.1% of people diagnosed with the disease reported at least one traumatic childhood experience.
Dr Karen Williams, who runs Australia’s first women’s-only trauma hospital, the Ramsay Clinic Searle in New South Wales, says borderline personality disorder is “a gender-specific diagnosis given to women with a history of abuse”. Whereas when we see a man come back from abuse, a traumatic event, we [say] he has PTSD [post-traumatic stress disorder]”.
“There are no symptoms that people with borderline personality disorder don’t see in people with PTSD.”
Williams says it often takes several sessions to spot a problem. patient abuse. She says reactions of dissociation and forgetting the trauma are very common. Also, not all patients recognize their experiences as traumatic.
Although there is no clinical difference between PTSD and BPD, the clinical responses are markedly different, Williams says. While PTSD is treated sympathetically, especially among veterans, women diagnosed with BDP are considered “difficult.”
Mr Williams, like Professor Jayashri Kulkarni, director of the Monash Alfred Psychiatric Research Centre, prefers the term ‘complex post-traumatic stress disorder’ to BPD. Kulkarni says the BPD label implies that the behavior is part of a personality style. There is an implicit “hard moral approach” that these people should be able to control themselves, an attitude that feeds prejudice.
But the more she researches borderline personality disorder, she says, the more it becomes clear that “women and men labeled with borderline personality disorder often have severe childhood trauma.” ” he says.
“I really think it’s unfair to tell people who’ve been through hell since the beginning of their lives that they’re talented. There is a serious flaw in their inner core. ”
Examples of the term personality disorder
For Chanen, the term “personality disorder” is useful because it captures the identity and relationship difficulties that he says are at the heart of the problem.
he points to the people child abuse research A paper published in 2023 shows that nearly two-thirds of the population has experienced some form of adversity during childhood. Nevertheless, BPD is relatively rare, occurring in only 1% to 3% of the population.
“There is something important going on within each individual that interacts with the experience of adversity. That interaction can cause borderline personality disorder, but it can also cause other disorders such as depression. They can have a different gender, and they can have no mental disorder,” he says.
“That’s not to say that adversity isn’t important, but it’s not inevitable that people will develop mental disorders, and it’s certainly not inevitable that people will develop borderline personality disorder.”
Chanen believes that reductionist arguments about causes are “oversimplified, wrong, and unfortunately harmful to people living with personality disorders.” He said the debate over renaming the disorder Complex PTSD “is not scientifically supported and undermines moral arguments about respect, dignity and equal access to effective services.” “I believe.
Chanen said the name change could have the unintended consequence of invalidating the experience of patients who have not experienced trauma or leading clinicians to believe trauma is present without any evidence. Are concerned. Rather, he believes early intervention is the key.
Associate Professor Loyola MacLean from the University of Sydney, who identifies as a Yamacchi woman, said of the division of opinion within the profession:
“I think we need to be open-minded that this adverse experience may be a contributing factor, a trigger, or a causal effect for some people.” , says MacLean, a consultant psychiatrist and psychotherapist.
“We know that trauma, especially early trauma, is a huge risk factor for downstream health problems across a range of health problems because that’s where the body and the brain really develop.”
Although the physical and the psychological are deeply intertwined, “the entire Western world still suffers from a kind of Cartesian divide,” she says.
changing approach
The debate over the use of BPD or complex post-traumatic stress disorder is more than just words, according to Kulkarni, it changes the entire direction and focus of treatment.
Historically, treatment for borderline personality disorder has relied on antidepressants to treat depressed mood and antipsychotics to treat paranoid thoughts; It does not address underlying cognitive symptoms such as difficulty managing emotions, disrupted identities, disrupted relationships, and impulsivity.
These symptoms tend to be treated with psychosocial approaches such as dialectical behavior therapy, mentalization-based therapy, and quality care.
Mr Kulkarni and Dr Evelyn Mu of the Monash Alfred Psychiatric Research Center are running clinical trials of new drugs that target the neurochemistry thought to cause symptoms of BPD/Complex Post Traumatic Stress Disorder.
The effect of trauma on the body’s stress levels means that the glutamate system, the main neurotransmitter in the nervous system, is in overdrive, Mu says. Her theory is that this causes cognitive dysfunction.
Since it began in 2022, 200 people have participated in a randomized, controlled, double-blind clinical trial of memantine. Memantine, a drug approved by regulators to treat people with Alzheimer’s disease, is a drug that blocks glutamate receptors in the body.
Williams Women’s Trauma Hospital is also considering new ways to treat acutely ill patients. She says the only place acutely suicidal patients can go is in a mixed-gender room in a hospital’s psychiatric ward., There are no keys and there can be a lack of supervision for mentally ill, drunk or detoxing male patients. Sexual assaults occur frequently in such wards.
It’s an environment that exacerbates symptoms, she says.
In contrast, the three-week program her patients receive includes education about exercise, self-care, and healthy relationships.
“In most cases, not only do they have trauma from their childhood, they still carry it,” Williams said. “We know that people who have been abused tend to fall back into abusive relationships because they have such low self-worth and don’t know that they deserve to be treated better. .”
Hospital beds are always filled with patients who can afford private treatment, some of whom come from interstates. Only one of his 40 beds at this hospital is funded by public funds.
Ms Williams said her program has improved patients’ quality of life, allowing many to work full-time or return to study. She said, “Many of them said, ‘I want to be a nurse, I want to come back and work here.'”
Kulkarni says another new solution is to get rid of labels. “It’s hurting people…A new perspective gives us new compassion and new understanding.”
