The convergence of the trauma and personality disorders fields Dr Andrew Moskowitz Department of Mental Health NHS Grampian Specialist Psychotherapy Services

My background Trauma and dissociation - and psychosis Knowledge of PD comes primarily from trauma and forensic fields Talk more appropriate called relevance of trauma field for PD

Overview of talk A bit about PD An outline of trauma and PTSD Borderline Personality Disorder and Complex PTSD - Herman and others Structural dissociation - Van der Hart & Nijenhuis The dissociative nature of PD? - Bromberg Attachment Secure Insecure Disorganised/disoriented

What I know about PD Historical background moral insanity - psychopathy, narcissism Hysteria - BPD Bleulers simple schizophrenia - schizoid, schizotypal PD (US:UK study) BPD same as other PDs? Nosological approach becoming dimensional? Adaptive in nature Attachment perspective: disorganised in infancy, controlling in childhood, unstable in adulthood (HH) Analyst Bromberg -- all PDs dissociative, adaptive

What does the word trauma mean? Derives from the Greek word for wound Used for over 300 years to describe medical wounds First used in a psychological sense about 100 years ago, by William James Certain reminiscences of the shock fall into the subliminal consciousness… If left there, they act as permanent psychic traumata, thorns in the spirit, so to speak.

History of PTSD faking it vs breaking it Soldiers heart, shell shock, railway spine 1970s: The Vietnam War, battered womens syndrome, rape, natural disasters

The Trauma component of PTSD (DSM-IV Diagnosis) PTSD is a disorder involving stress – a disturbed stress response, which occurs after (post) a traumatic event The A criterion – definition of trauma – is quite broad: The person has been exposed to a traumatic event in which both of the following were present: the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror Trauma overwhelms ones capacity to process it - producing dissociation?

The Symptom components of PTSD (DSM-IV Diagnosis) One (1) Re-experiencing symptom, such as flashbacks and nightmares Three (3) Avoidance and Numbing symptoms, such as avoiding things that remind one of the trauma, and feeling detached or estranged from others Two (2) Hyperarousal symptoms, such as hypervigilance or sleep difficulties Clearly linked to one (1) trauma and lasting at least one (1) month

Shattered assumptions Traumatic events shatter the assumptions people hold about the world, other people, and themselves – assumptions needed in order to feel safe, deal comfortable with others, and have confidence in themselves. Natural disasters shatter assumptions of the world being a safe place – earthquakes in particular shatter assumptions of the world being stable – the ground is not supposed to move beneath ones feet. Violent crimes, particularly committed by strangers, shatter the assumption that people can be trusted. Certain other interpersonal traumas may affect views of oneself – an inability to protect oneself and/or loved ones affects feelings of competence and confidence.

Problems with PTSD diagnosis Significant co-morbidity and sub- threshold PTSD All symptoms must originate with the trauma and relate to only one trauma Aftermath of ongoing or chronic trauma does not conform to PTSD diagnosis

Borderline Personality Disorder and child abuse Childhood trauma, particularly sexual abuse is, in BPD samples: very common (60-75%) more frequent and begins earlier than in other PDs (Yen et al, 2002) often severe (at least 1/week for at least 1 year - Zanarini et al, 2002) associated with increased symptomatology increases the risk of suicide 10-fold in BPD populations (Soloff et al, 2002)

Symptom criteria (DSM-IV) for BPD (stable instability) Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of overidealisation and devaluation Identity disturbance Impulsivity Recurrent suicidal behaviour, gestures, or threats, or self- mutilating behaviour Affective instability Chronic feelings of emptiness Inappropriate, intense anger (or difficulty controlling anger) Transient, stress-related paranoid ideation or severe dissociative symptoms

Voices in BPD Common Not transient Not pseudo-hallucinations (no such thing) Not a psychotic symptom

1. Complex PTSD Coined by Judith Herman (1992) Trauma and Recovery Core feature of ongoing trauma is captivity. A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organised sexual exploitation Chronic abuse in childhood same as in adulthood? Developing brain, adaptation to environment, use- dependent organisation (states become traits, Bruce Perry)

Complex PTSD (or DESNOS) Alterations in emotional regulation This may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger Alterations in consciousness This includes things such as as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body Changes in self-perception This may include a sense of helplessness, shame, guilt, stigma, and a sense of being completely different than other human beings Alterations in the perception of the perpetrator For example; attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge Alterations in relations with others Variations in personal relations including isolation, distrust, or a repeated search for a rescuer Changes in one's system of meanings This may include a loss of sustaining faith or a sense of hopelessness and despair

2. Structural dissociation (Van der Hart, Nijenhuis, & Steele, 2006) Simple PTSD involves one central split/dissociation in the personality one part that is immersed in the trauma (the Emotional part of the personality or EP) and One part that tries to avoid reminders of the trauma at all costs (the Apparently normal part of the personality -- AP). Originally coined by C.S. Myers in WWI EP is typically organised around evolutionary- based animal defence systems AP is organised around daily activities

Secondary structural dissociation and BPD One AP, though often very constricted Many areas of daily life associated with traumas triggers (eating, sexuality), particularly interpersonal relations EP is split into several, often organised around animal defence systems (fight, flight, freeze, submission)

3. Philip Bromberg Interpersonal analyst PDs involve ego-syntonic dissociation. Essential rigidity is dissociative in nature. Defines PDs as: the characterological outcome of the inordinate use of dissociation in the schematization of self-other mental representation Independent of type, PD reflects a mental structure organised in part as a protective protection against the potential repetition of early trauma The distinctive personality traits of each type of PD are embodied within a mental structure that allows each trait to be always on-call for the trauma that is seen as inevitable.

4. Attachment Bowlby, Ainsworth, Main (Fonagy) Secure and insecure attachment Evolutionary basis - seeking comfort in a person, not a place Darwin & the sea lizard Conditioned fear to guns Strange situation Secure attachment Insecure (when parental figure is inadequate)

Disorganised attachment fright without solution When parent is the source of danger (as well as its only solution - approach/avoidance conflict As a result of severe trauma But also as a result of frightened/frightening/dissociative faces (2nd generation unresolved loss/trauma) Become controlling children (punitive/parentified or solicitous) -- aggressive, BPD/DD adults?

Adult attachment interview Secure/autonomous Ward et al, 2006 Dismissing - idealised caretakers, contradictory & impoverished memories (high PD) - ANP? Preoccupied - overly detailed, anger and affect over past events - (anxious/depressed disorders) EP? Unresolved losses, traumas - high psychopathology when alternate classification not secure

Treatment approaches Reconceptualise bad and good objects into victim, perpetrator and rescuer identities - all relationships viewed in such terms Advantages of multiple treaters Utilise AAI in treatment outcome studies