Trauma Reenactment: Rethinking Borderline Personality Disorder When Diagnosing Sexual Abuse Survivors

Article excerpt

Adult survivors of sexual trauma often experience symptoms related to their childhood experiences that are analogous to many of the diagnostic criteria of Borderline Personality Disorder (BPD). This article examines these symptoms in the context of a trauma framework and postulates that mental health counselors need to consider if the symptomatic behaviors are more indicative of a post-traumatic response, specifically trauma reenactment. Recognizing self-harming behaviors in adult survivors as reenactments of childhood sexual trauma rather than characterological manifestations of personality deficits serves to improve the quality of care of such clients in that mental health counselors may then focus on the unresolved issues rather than personality restructuring. Thus, understanding clients from a trauma framework can minimize the stigma that is often associated with the diagnosis of BPD and provide a more objective treatment climate.

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Borderline Personality Disorder (BPD) has been a topic of interest for mental health professionals for some time. Literature abounds discussing the etiology and effective treatment methodology for individuals with this diagnosis. In recent years, the professional literature has attended to the similarities between BPD and Post Traumatic Stress Disorder (PTSD) (Hodges, 2003; Murray, 1993). Miller (1994) suggested that BPD might, in fact, be misdiagnosed in cases of sexual abuse survivors. Rather than a diagnosis of BPD, the symptomology of the client may be more reflective of a Post Traumatic Stress Disorder (PTSD) diagnosis, and, more specifically, in line with trauma reenactment. Although not a diagnostic category recognized by the American Psychiatric Association (APA, 2000), for the purpose of this article, trauma reenactment will be considered a form of PTSD.

Freud (1920) suggested that individuals who survived traumatic events may develop what he termed traumatic neurosis. One consequence of traumatic neurosis is the survivors' compulsion to repeat elements of the traumatic event. Similar to Freud's concept, Miller (1994) postulated that adult survivors of childhood sexual trauma who engage in self-injurious behavior, engage in risk-taking behaviors such as promiscuity and substance abuse, and experience difficulties in interpersonal relationships, are actually reenacting behaviors symbolic of trauma suffered in childhood. Types of reenactment these individuals engage in may include (a) behavioral (i.e., inflicting harm to self or others), (b) self destructiveness (i.e., subconsciously sabotaging situations such that it leads to feelings of revictimization), and (c) reexeperiencing (flashbacks).

Several theories exist which attempt to explain the etiology of these reenactment behaviors. One such theory was proposed by van der Kolk (1989). He posited that these individuals are addicted to the trauma and, therefore, may try to recreate it (i.e. a victim of childhood sexual abuse may become a prostitute). Such individuals have reported feeling bored, apprehensive, and anxious when not experiencing some form of activity reminiscent of their trauma. Miller (1994) suggested that this arousal need can be an impetus for reenactment behaviors. For children who experience trauma, these experiences became synonymous with relationships and the child is often in a constant state of arousal due to fear, rage, hyperalertness, or anxiety. This constant arousal impacts the biochemistry of the child and inhibits a return to a baseline. Thus, as an adult, the individual may be addicted to excitement which is painful, while also to them, pleasurable and comfortable. Further, van der Kolk (1989) reported that high levels of stress activate the physiological opioid systems. Just as heroin may activate this system and create a cycle of dependence and withdrawal, so might the hyperarousal that is created with trauma. Self-injurious behaviors perpetuate this cycle by producing the stress related opioid stimulation. …