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Is this actually PTSD? Clinicians divided over redefining borderline personality disorder | Mental health


When Prof Andrew Channen was a trainee psychiatrist in 1983, patients with borderline personality disorder (BPD) who self-harmed were ‘vilified’ and ‘treated appallingly’.

“There was this myth that somehow they were indestructible,” he says. Despite what his teachers told him, “most were dead by the end of my studies.”

More than four decades later, Chanen is chief of clinical practice and director of personality disorder research at Orygen, the National Center of Excellence in Youth Mental Illness Hello at the University of Melbourne and he says BPD remains the most stigmatized and discriminated against mental health disorder in Australia and internationally.

Overwhelmingly diagnosed in womenBPD is characterized by difficulty controlling emotions, rapid mood swings, self-harm often accompanied by suicidal thoughts, and an unstable self-image.

Some Australian clinicians are calling for BPD to be recognized as a trauma disorder rather than a personality disorder, arguing that this would lead to better treatment and outcomes.

The argument for rethinking BPD

American psychoanalyst Adolph Stern introduced the word “borderline” into psychiatric terminology in 1938. using it to describe a group of patients that fit neither the neurotic nor the psychotic diagnostic categories.

Several studies have shown that BPD is associated with child abuse and neglect more than any other personality disorder, but rates can vary from from 90% to 30%. Ann analysis of 97 studies found that 71.1% of people who were diagnosed with the disorder reported at least one traumatic childhood experience.

Dr Karen Williams, who runs the Ramsay Clinic Thirroul in New South Wales – Australia’s first all-women trauma hospital – believes BPD “is ​​a gender-based diagnosis given to women who have had a history of abuse, whereas when we see a man coming back from a traumatic event, we [say] he has PTSD [post-traumatic stress disorder]”.

“There isn’t a symptom that a person with borderline personality disorder has that a PTSD patient doesn’t have.”

Williams says it often takes several sessions before she uncovers a of the patient abuse. The dissociation and trauma response of forgetting is very common, she says. Furthermore, not all patients recognize their experiences as trauma.

Although there is no clinical difference between PTSD and BPD, Williams says the clinical response varies widely. PTSD, especially among veterans, is treated sympathetically, while women diagnosed with BDP are considered “difficult.”

“Injustice”: Prof. Jayashree Kulkarni. Photo: Nadir Kinani/The Guardian

Williams prefers the term ‘complex post-traumatic stress disorder’ to BPD, as does Prof Jayashree Kulkarni, the director of Monash Alfred Psychiatry Research Center. Kulkarni says the BPD label suggests that the behavior is part of a personality style. There is an implied “strict moralistic approach” that these people should just be able to control themselves – and this attitude contributes to the stigma.

But she says the more she researched BPD, “the more apparent it became that women and men who were labeled with this condition often had terrible trauma early in their lives.”

“I really think it’s unfair to tell someone who has been through hell in their early life and beyond that they have a significant flaw in their inner core.”

The case for the term personality disorder

For Chanen, the term “personality disorder” is useful because it captures the difficulties in identity and relationships that he believes are at the heart of the problem.

He indicates a national childhood maltreatment research published in 2023, which showed that nearly two-thirds of the population experienced some form of childhood disadvantage. However, BPD is relatively rare, occurring in only 1% to 3% of the population.

“There is something important going on in each individual that interacts with the unhappiness experienced. While this interaction can lead to borderline personality disorder, it can also lead to another disorder, such as depression or no mental disorder at all,” he says.

“That’s not to say that adversity is unimportant, but it’s not inevitable that a person will develop a mental disorder, and it’s certainly not inevitable that they’ll develop borderline personality disorder.”

Channen believes that any reductionist arguments about causes are “oversimplified, flawed, and unfortunately harmful to people living with a personality disorder.” He believes the debate surrounding renaming the disorder complex PTSD “is not really supported by science and weakens the moral case for respect, dignity and equal access to effective services.”

Chanen is concerned that changing the name could have the unintended consequence of invalidating the experiences of patients who have not experienced trauma, or lead clinicians to assume that trauma is present without any evidence. Instead, he believes early intervention is key.

An associate professor at the University of Sydney, Loyola MacLean, who identifies as a Yamaji woman, says of the divided opinions within her profession: “It’s possible to talk about two halves of the same whole.

“I think we have to be open that this adverse experience can contribute, trigger, and for some people have a causal element,” says McLean, who is a psychiatrist and counseling and liaison psychotherapist.

“Trauma — particularly early trauma, because that’s where the body and the brain really develop — we know that’s such a huge risk factor for subsequent health problems across the spectrum of health problems.”

The physical and the psychological are deeply connectedshe says, but “the whole Western world still suffers from a sort of Cartesian divide.”

Borderline personality disorder is associated with child abuse and neglect more than any other personality disorder, according to several studies. Photo: Dominic Lipinski/PA

A variable approach

Discussing the use of BPD, or complex PTSD, is more than words – according to Kulkarni, it changes the entire direction and focus of treatment.

Historically, BPD treatment has relied on antidepressants to treat low mood and antipsychotics to treat paranoid thinking, but there unresolved underlying cognitive symptoms such as difficulty managing emotions, impaired sense of identity, impaired relationships, and impulsivity.

These symptoms tend to be treated with psychosocial approaches, such as dialectical behavior therapy, mentalization-based treatment, and high-quality care.

Kulkarni and Dr Eveline Mu of the Monash Alfred Psychiatry Research Center are conducting clinical trials for new drugs that target the neurochemistry they believe causes the symptoms of BPD/PTSD.

Dr. Evelyn Mu. Photo: Nadir Kinani/The Guardian

The effects of trauma on the body’s stress levels mean that the glutamate system—the main neurotransmitters of the nervous system—is in overdrive, Mu says. Her theory is that this leads to cognitive dysfunction.

Since it began in 2022, 200 people have taken part in the randomized controlled double-blind clinical trial of memantine, a drug the regulator has approved to treat Alzheimer’s patients that blocks the body’s glutamate receptors.

Williams’ women-only trauma hospital is also exploring new ways to respond to those with acute symptoms. She says the only place acutely suicidal patients can go is the men’s and women’s rooms in hospital psychiatric wards, which do not have locks and may lack supervision of male patients who are often psychotic, drunk and detoxing. Sexual violence is often widespread in such departments.

It’s an environment that exacerbates symptoms, she says.

In contrast, the three-week program her patients undergo includes exercise, self-care and healthy relationship training.

“Almost all the time, they don’t just have childhood trauma, they still have it now,” Williams says. “We know that people who have been abused tend to end up back in abusive relationships because they have such low self-esteem and don’t know that they deserve to be treated better.”

Hospital beds are constantly filled with patients who can afford private treatment, some even coming from interstates. Only one of the hospital’s 40 beds is publicly funded.

Williams says her program has improved the quality of life for her patients, with many able to take on full-time jobs or return to school. “A lot of them said, ‘I want to be a nurse, I want to come back and work here.’

Kulkarni says one of the other new solutions is to get rid of the label. “It hurts people. . . . Seeing in a new way offers us new compassion and new understanding.”

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