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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. To further substantiate this theory, van der Kolk highlighted the benefits of opioid receptor blockage medications in decreasing self-mutilative behaviors.
Miller (1994) suggested that the process of trauma reenactment is cyclical and includes thoughts, feelings, and behavior that can be interpreted at any point in the cycle. At one point, the cycle could be interpreted as feelings of rage, shame, or fear causing an individual to inflict self-harm. At another juncture, it could be interpreted that self-harming causes disgust that results in further punishment, or finally, it could be interpreted that when an interpersonal relationship becomes too intimate the individual feels compelled to detatch through self-harming behaviors. The self-abuse cycle serves to protect the trauma survivor as it keeps others at a distance. The self-protective function of self-harming behaviors is necessary as survivors are often unable to self-protect and typically maintain diffuse boundaries in interpersonal relationships. Paradoxically, these individuals also want to be rescued and protected. Together these tendencies create relational instability.
In this article, we discuss the impact of childhood sexual abuse on development and attachment and how traumatic experiences in childhood may result in reenactment behaviors as adults. We then explore the association between reenactment symptoms and the DSM-IV-TR diagnostic categories of BPD and PTSD. Finally, we challenge the use of the BPD diagnosis when treating survivors of sexual trauma as such a diagnosis may not be clinically accurate and may have a stigmatizing impact that can be more harmful than beneficial.
IMPACT OF TRAUMA ON DEVELOPMENT
Traumatic childhood experiences may impede the normal developmental process. Janet (1911) suggested that personality development is halted by traumatic experiences. Consequently, the individual is unable to accommodate and assimilate new information from experiences, thus disturbing his or her ability to cope with future challenges. This ultimately leaves the individual unable to integrate the traumatic material into existing cognitive schemas. According to Freud (1920), individuals who are unable to assimilate traumatic experiences into the memory system repeat the repressed material as contemporary experiences and, as suggested by van der Kolk (1989), are not likely to make a conscious connection between past experiences and current reenactments.
It has been postulated that cognitive distortions result...
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