Academic journal article Canadian Psychology

Borderline Personality Disorder: Disorder of Trauma or Personality, a Review of the Empirical Literature

Academic journal article Canadian Psychology

Borderline Personality Disorder: Disorder of Trauma or Personality, a Review of the Empirical Literature

Article excerpt

Over the past 30 years, the deleterious impact of childhood trauma (CT; i.e., child sexual abuse, child psychological or physical neglect, parental violence, witnessing intimate partner violence, and other types of child maltreatment) has been well established in the literature. CT has been associated with a wide range of pervasive difficulties in all areas of adult functioning including psychological (e.g., Briere, Hodges, & Godbout, 2010; Godbout & Briere, 2012) and relational difficulties (e.g., Godbout, Dutton, Lussier, & Sabourin, 2009; Godbout, Lussier, & Sabourin, 2006; Godbout, Runtz, MacIntosh, & Briere, 2013). In one particular line of inquiry, researchers began to explore the question of whether a history of childhood sexual abuse (CSA) or other forms of CT, especially when committed by an attachment figure (i.e., "highbetrayal trauma"; Freyd, 1996; Kaehler & Freyd, 2009), played a causal role in the development of borderline personality disorder (BPD; Herman, Perry, & van der Kolk, 1989; Landecker, 1992). As this discussion emerged in the literature, so too did the question of whether BPD was the most appropriate diagnosis to better reflect the symptomatology of CSA survivors, whose clinical presentation was more complex than other adult trauma survivors diagnosed with posttraumatic stress disorder (PTSD; Herman, 1992; Pearlman, 2001; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).

BPD continues to be a controversial diagnosis with this controversy being based on the significant symptom overlap with other disorders including PTSD and other axis I disorders (Pagura et al., 2010; Zanarini et al., 1998), the diversity of patients receiving the diagnosis (Maffei, 2005), and the lack of support in the literature regarding the reliability and validity of BPD as a diagnostic entity (Becker, 2000; Gunderson, 2009). Over time the diagnosis of BPD came to have significant negative connotations in the minds of many clinicians, whereby individuals diagnosed with PTSD were more likely to be viewed as victims of traumatic events rather than possessing intractable personality problems (Quadrio, 2005). However, the symptom complexity (Hodges et al., 2013) or simultaneous presence of multiple, different types of symptomatology in the same trauma survivor was not well represented by the diagnostic category of PTSD (e.g., Briere et al., 2010; van der Kolk et al., 2005). One of the main preoccupations of clinicians and researchers has been to better understand the etiological origins of BPD to formulate well-tailored approaches to prevention and intervention.

In the initial literature considering these questions, authors consistently reported associations with CT, CSA in particular (Herman et al., 1989; Zanarini et al., 1997). These researchers posited that survivors of CT, especially severe long-lasting CT, were suffering from a complex form of PTSD, Complex PTSD, or Disorders of Extreme Stress Not Otherwise Specified (DESNOS) that shared many similarities with BPD including affect dysregulation, impulsivity, suicidality, feelings of emptiness and other identity impairments, chronic interpersonal difficulties, abandonment issues, anger, and dissociation (Pearlman, 2001; Roth et al., 1997; van der Kolk et al., 2005). This debate has continued to date with researchers assuming positions encompassing a wide expanse of conceptualizations of BPD. These range from the position that BPD is "little more than a sophisticated insult" (Herman, 1992, p. 123) and that the symptoms identified in most trauma survivors (mis)diagnosed with BPD reflect Complex PTSD (Briere et al., 2010; Ford, Courtois, Coutois, & Ford, 2009; Herman, 1992; Herman et al., 1989), all the way to positions that suggest a strong genetic and neurobiological foundation for the disorder regardless of trauma history.

At the heart of this controversy is a diagnostic conceptual confusion. …

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