When Prof Andrew Chanen was a trainee psychiatrist in 1993, patients with borderline personality disorder (BPD) who had 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 training”.
More than three decades later, Chanen is the chief of clinical practice and head of personality disorder research at Orygen, the National Centre of Excellence in Youth Mental Health at the University of Melbourne, and he says BPD remains the most stigmatised and discriminated against mental health disorder in Australia and internationally.
Overwhelmingly diagnosed in women, BPD is characterised by difficulty managing emotions, rapid mood changes, self-harm often accompanied by suicidal thoughts, and an unstable self image.
Some Australian clinicians are calling for BPD to be recognised as a trauma disorder rather than a personality disorder, arguing this would lead to better treatment and outcomes.
The argument for rethinking BPD
American psychoanalyst Adolph Stern introduced the word “borderline” to psychiatric terminology in 1938, using it to describe a group of patients who fitted neither the neurotic nor the psychotic diagnostic categories.
Several studies have shown BPD is associated with child abuse and neglect more than any other personality disorders, but the rates can vary from as high as 90% to as low as 30%. An analysis of 97 studies found 71.1% of people who were diagnosed with the condition reported at least one traumatic childhood experience.
Dr Karen Williams, who runs New South Wales’s Ramsay Clinic Thirroul – Australia’s first women-only trauma hospital – believes BPD “is a gendered diagnosis that is given to women who have got histories of abuse, whereas when we see a man come back from a traumatic event, we [say] he’s got PTSD [post-traumatic stress disorder]”.
“There is no symptom that a borderline personality disordered person has that a PTSD patient doesn’t also have.”
Williams says it often takes several sessions before she can uncover a patient’s abuse. The response of dissociation and forgetting trauma is very common, she says. Also, not all patients recognise their experiences as trauma.
Despite there being no clinical difference between PTSD and BPD, Williams says the clinical response varies markedly. PTSD, particularly among veterans, is treated with sympathy, while women with the diagnosis of BDP are considered “difficult”.
Williams prefers the term “complex post-traumatic stress disorder” to BPD, as does Prof Jayashri Kulkarni, the director of the Monash Alfred Psychiatry Research Centre. Kulkarni says the BPD label implies the behaviour is part of a personality style. There’s an implied “stern moralistic approach” that these people should just be able to control themselves – and that attitude contributes to stigma.
But she says the more she has researched BPD, “the more obvious it seems the women and the men who have been labelled with this condition often have dreadful early life trauma”.
“I really think this is injustice, to say to somebody who’s gone through hell in their early life and onwards, that they’ve got a significant flaw of their inner core.”
The case for the term personality disorder
To Chanen, the term “personality disorder” is useful because it captures the identity and relationship difficulties he says are at the heart of the issue.
He points to a national study of childhood maltreatment published in 2023 which showed nearly two-thirds of the population experience some form of childhood adversity. Despite that, BPD is comparatively rare, occurring in only 1% to 3% of the population.
“There’s something important going on in each individual that interacts with the experience of adversity. While that interaction might give rise to borderline personality disorder, it might also give rise to another disorder, such as depression, or no mental disorder,” he says.
“That’s not to say that the adversity is unimportant, but it’s not inevitable that a person will develop a mental disorder, and certainly not inevitable that they will develop borderline personality disorder.”
Chanen believes any reductionist arguments about causes are “oversimplified, wrong and unfortunately harmful for people living with personality disorder”. He believes the debate around re-naming the disorder as complex PTSD is “not really supported by the science and weakens the moral argument for respect, dignity and equality of access to effective services”.
Chanen is concerned a name change may have the unintended consequence of invalidating the experiences of patients who have not experienced trauma, or prompt 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 McLean, who identifies as a Yamatji woman, says of the divided opinions within her profession: “It could well be that we’re talking about two halves of the same whole.
“I think we’ve got to keep an open mind that this adverse experience may be contributing, triggering, and for some people will have a causal element,” says McLean, who is a consultation-liaison psychiatrist and psychotherapist.
“Trauma – in particular early trauma, because that’s where the body and brain are really developing – we know that it’s such a huge risk factor for downstream health problems across the spectrum of health problems.”
The physical and the psychological are deeply connected, she says, but “the whole of the western world is still suffering from a kind of a Cartesian divide”.
A shifting approach
The discussion about using BPD or complex post-traumatic stress disorder is about more than words – according to Kulkarni, it changes the whole direction and focus for treatment.
Historically, treatment for BPD has relied upon antidepressants to treat low mood and antipsychotics for paranoid thinking, but it has not addressed underlying cognitive symptoms such as difficulty managing emotions, a disturbed sense of identity, disturbed relationships and impulsivity.
Those symptoms tend to be treated with psychosocial approaches, such as dialectical behaviour therapy, mentalisation-based treatment and high quality care.
Kulkarni and Dr Eveline Mu at Monash Alfred Psychiatry Research Centre are running clinical trials for new drugs to target the neurochemistry they believe drives the symptoms of BPD/complex post-traumatic stress disorder.
The effects of trauma on the body’s stress levels mean the glutamate system – the primary neurotransmitters of the nervous system – is in overdrive, Mu says. Her theory is that this drives cognitive dysfunction.
Since it began in 2022, 200 people have participated in the randomised controlled double blinded clinical trial of memantine, a drug that the regulator has approved for treatment of Alzheimer’s patients, and which blocks the body’s glutamate receptors.
Williams’ women’s-only trauma hospital is also examining new ways of responding to those with acute symptoms. She says the only place where acutely suicidal patients can go are mixed-gender rooms in hospital psychiatric wards, which have no locks and can lack supervision of male patients who are often psychotic, drunk and detoxing. Sexual assault is often rife in such wards.
It’s an environment that exacerbates symptoms, she says.
By contrast, the three-week program her patients undergo involves exercise, self-care, and education about healthy relationships.
“Almost all the time, they don’t just have trauma from their childhood, but they’ve still got it now,” Williams says. “We know that people who have been abused tend to end up in abusive relationships again, because they have such little self value and they don’t know that they deserve to be treated better.”
The hospital’s beds are constantly full with patients who can afford private treatment, with some even coming from interstate. Only one of the hospital’s 40 beds is publicly funded.
Williams says her program has improved the quality of life of her patients, with many able to take on full-time work or go back to study. “Many of them have 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’s hurting people … Taking a new look offers us new compassion and new understanding.”
• This article was amended on 12 May 2024 to correct the year in which Prof Andrew Chanen was a trainee psychiatrist. It was 1993, not 1983.
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