Childhood PTSD Roots of Borderline Personality Disorder, ♥ psychologia - inne (książki, artykuły), [EN] ...

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SIS J. Proj. Psy. & Ment Health (2011) 18 : 04-13
Childhood PTSD Roots of Borderline Personality Disorder-
Emotionally Unstable Personality Disorder
Walter M. Case and Bankey L. Dubey
In recent years there has been a growing controversy regarding the validity of the APA diagnosis of
Borderline Personality Disorder. This categorization is not recognized internationally and perhaps
the closest approximation internationally in the ICD-10 is "Emotionally Unstable Personality
Disorder". A clinical case history is presented involving an adult male, who presented with a
childhood background of PTSD and ADHD. His personality problems became apparent in late
adolescence. As an adult, he self medicated with alcohol and street drugs for handling bouts
of severe depression. When this failed, he sought treatment and revealed his inner tormented
world through symbolic dreams and SIS imagery. These presented time capsule "pictures" of his
"borderline" life style traceable to trauma in a dysfunctional family.
The medical model has provided a conceptual basis for much progress in diagnosis and
treatment of mental disorders. This has especially proven to be the case in the Schizophrenic
Disorders and severe Affective Disorders. For these, modern genetic research and the
documented efficacy of evidence based psychopharmacologic treatment conceptually support
pathophysiologic formulations regarding their etiology.
The medical model approach to diagnostic categorization has less scientific strength in
regard to symptom constellations that lack documented objective biological criteria such as
Posttraumatic Stress Disorder (PTSD) and Borderline Personality Disorder. Relative to the
frequently observed temporal interaction between these two particular disorders, a child who
is repeatedly subjected to abuse in a dysfunctional family may be prone to develop lifelong
features of Posttraumatic Stress Disorder (PTSD) and beginning in late adolescence an
emotionally unstable personality. Although this is frequently observed in clinical practice, the
causal connection is not always clear (McMain et al 2003). In attempts to scientifically provide
basic answers, there have been many clinical investigations purporting to isolate underlying
biological abnormalities in Borderline Personality Disorder (Berlin et al, 2005, Donegan et al,
2003, Prossin et al, 2010, Stanley and Stanley, 2010). Psychotherapy outcome studies have
also been statistically studied (McMain et al, 2009).
This case history study assessing symbolic imagery from a PTSD dream and SIS-II Booklet
promises to throw light on this subject in an adult diagnosed with Borderline Personality
Disorder, who was traumatized in childhood. It will illustrate how analyzing dream and SIS
symbols in the same individual throughout the course of the person's lifetime can be facilitated
by blending insights from both symbolic sources. In order to conceptualize the role of childhood
stress in activating PTSD dreams and symbolic defense mechanisms, the following body-
mind-spirit conceptual model of Nature's homeostatic healing process is proposed.
The simplest form of PTSD involves a relatively mature symptom free individual, who
experiences one highly stressful time limited event. For purposes of illustration, consider a
Walter M. Case, M.D.
and
Bankey L. Dubey,
Ph.D., DPM, Director, SIS Center, 4406 Forrest
Road, Anchorage, AK 99507(USA) Email: bldubey@gmail.com
Key Words
: Childhood PTSD, Borderline Personality Disorder, Unstable Personality Disorder
Childhood PTSD Roots 5
simplistic case history involving a man who was traumatized in an industrial explosion. Such
a severely stressed victim would be expected to immediately develop recurrent "nightmares,
realistically depicting the circumstances of the accident. The severity of his psychological
symptoms, as well as their persistence, would partially relate to his genetic vulnerability to
handling stress.
This is Nature's way for homeostatic healing, perhaps not just in humans, but in all living
creatures possessing a higher functioning nervous system. During the relaxed state of sleep,
the brain's memory neurons involuntarily (i.e. out of "conscious control") repeatedly replay
affect charged imagery depicting subjective perception of the external traumatic event.
Repetitive experiencing of the stress or "neural electrochemical sensory playback" serves
two basic functions: one is to impress upon the organism's memory storage, by reinforcing
cognitive clues concerning what external events would be most likely to pose future potential
Stressors (e.g. a threatening carnivore). The second is to create an internal mechanism of
"nervous system reconditioning". Repeatedly experiencing traumatic memories in the relatively
low state of autonomie nervous system arousal during sleep, gradually reconditions memory
neurons. This occurs in the brain's PTSD memory center, by removing the dysphoric affect
bound to the PTSD imagery and their concomitant somatic sensations.
The language ability of humans enables them to communicate symbols of the threatening
imagery that sleep activated neural inhibitory mechanisms involuntarily introduced over recurrent
nights of dreaming. These maintain a balance between the "Nature's Behavioral Therapy" need
to have the dreamer experience a degree of necessary affect discomfort, by means of Autonomie
Nervous System monitored "Stress Exposure" that limits dream arousal. (This formulation
is consistent with clinical studies indicating that for significant therapeutic progress in PTSD
situations, the victim usually improves more rapidly in treatment programs, incorporating some
degree of experiencing dysphoric affect exposure, involving memory recall of the triggering
Stressors.) In any case, the monitoring functions are vital, so that the sleeper does not wake up
with, for example, a pounding heart or other somatic symptoms of arousal.
Thus for example. Nature's healing process occurs, that instead of dreaming of an explosion
in an occupational setting, the victim experiences lower levels of stressful symbols such as
involuntarily dreaming of a minor fire in a microwave. Until resolved, the victim's precarious
emotional state may be triggered by viewing similar type explosions either in the real world
or in the media.
A central requirement in the above theoretical model involves the necessity of the PTSD dreams
(and similarly SIS symbols) to be partially disguised. Thus, even those trained in symbolic
analysis can't fully cognitively appraise the symbolic significance of their own symbols. Of
course, when primitive humans expressed their dreams around camp fires, others could
well understand and translate their meaning. Thus, historically, the "therapeutic" sharing of
dream symbols and their empathetic interpretation by early "Witch doctors" or "Medicine men"
established the social roots of human culture, spirituality, and mythology/religion.
Finally, relative to this case, it might be noted that the immature nervous system of children
make them particularly vulnerable to PTSD and attention deficit disorders, especially if they
are socialized in a dysfunctional family.
6 Case and Dubey
Case History:
This study illustrates how stressful childhood interactions in a dysfunctional family can be
associated with PTSD, attention defects, severe suicidal depression, and subsequently,
personality problems lasting into adulthood. It involves the life of a large intelligent veteran
living in Buffalo New York. He had many characteristics of the tragic character in an ancient
Greek play. He had likeable "heroic" features to his character (e.g. A positive commitment
not to kill himself, so he could bring up his son in the best way possible, he had risked his life
in situations to help others, and his motivation for psychotherapy was real etc. He is a very
likeable man, who is easy to empathize with in psychotherapy).
Originally he sought treatment in a state of despondent suicidal ideation recurrence at age of
34. For years, he suffered from recurrent "nightmares". In such dreams, images of his violent
father would appear in a relatively close visual approximation to imaginary photographs of
the psychologically/physically abusive dysfunctional family scenes. Their terror linked affect
would disrupt his sleep. He would awake in panic experiencing psychophysiologic symptoms
of arousal, chief of which was "Stomach pain". On mornings after such disturbances, he would
have trouble concentrating in school and feel depressed for hours.
When older, away from his dysfunctional family, such concrete images of stressful past,
were gradually replaced with defensive dream symbols. During his highly stressful course
of psychosexual development, his resultant psychological scars ultimately impaired his
personality. He had acquired by late adolescence, what the American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR (fourth edition text
revision) categorizes on Axis II as a "Borderline Personality Disorder" and the International
Classification of Diseases and Related Health Problems (ICD-10) might categorize as an
Emotionally unstable personality disorder", but in the latter the diagnostic criteria are somewhat
different. As indicated earlier, such categorizations are subject to ongoing controversy, because
of questions about their validity as objective biological based clinical entities.
In America, where there is considerable interest in this syndrome, this pervasive chronic
"Disorder" is considered to be characterized by the followings clinical features: rapidly
shifting perception of self and others, impulsivity, intense mood fluctuations and superficial
interpersonal relationships. Transference distortions may arise from their tendency to oscillate
in the love-hate emotionally charged imagery projected or transferred onto the therapist -
oscillating from idealization to devaluation.
In retest SIS situations, the similar distorted patterns may be projected onto inkblot
representations of human figures. Often "Borderline" individuals will experience somatic
symptoms by projecting such distorted symbolic imagery onto their own body and SIS somatic
structure. Consistent with the latter, the man under discussion complained of "occasional lower
stomach pain", "pain in the lower back and ankles" and "headaches".
Like many individuals who meet diagnostic criteria for Borderline Personality Disorder, he
isolated himself from close social relationships in various ways (e.g.by working night shifts
as a taxi driver). Another manifestation was his long pattern of stormy relationships with
various psychologically marginal type "street women". After a short time, these romances
failed, and while grieving their loss his chronic recurrent depressive moods intensified. During
Childhood PTSD Roofs 7
such despondency episodes he usually experienced significant suicidal ideation. Over the
years he had sought treatment with various therapists. Characteristically, he only stayed
in psychotherapy briefly, without addressing his longstanding emotionally childhood PTSD
memories. Attempts to relate his dream and SIS symbolism to the latter, and to his adult
personality problems after a few sessions were resisted. He had a pattern of projecting negative
affect charged imagery depicting parental transference distortions onto his care providers.
This disruption of the therapeutic process was tragic, not only for himself, but also for his 9
year old son. With his boy, he was struggling within himself, as a parent, not to replicate the
dysfunctional relationship that he had experienced with his own abusive father.
His childhood concentration problems continued on into adulthood, to the extent that he met
diagnostic criteria for adult Attention Deficit Disorder. Fortunately, this had responded to stimulant
medication. However, management was complicated because he also had an episodic history
of alcohol and drug abuse. It also had been found that antidepressant medication had been
helpful, but he did not comply with recommendations for long term medication.
As indicated, he originally sought brief treatment at age 34. Next was at 39 and then finally at
48. On the last occasion, he was referred by a male veteran's administrator psychiatrist who
had been prescribing an unusually high dose of stimulant medication for his ADD symptoms.
The fact that the dosage far exceeded limits, set by community medication standards may
have reflected the severity of his concentration problems (or as he admitted to me, his giving
some of his drugs to his son).
In any case, his more recent psychiatrist correctly recognized that the prognosis for staying
in long term psychotherapy was guarded. Yet in his professional judgment, the two previous
short lived therapeutic trials with me had been partially helpful, so he recommended a third.
This historical time lapse study encompasses persistent symbolism between the first and
second therapy periods. The latter began with his spontaneously bringing into the first
psychotherapeutic interview, the following letter, which documented his ongoing motivation
for further psychotherapy, blending dream and SIS symbolic analysis:
"Dear Dr.Case
In the spring of 1965 I sought your help for answers and a treatment for y problems that were
controlling and ruining my life in the worst way. You initially prescribed medication that helped
me with my sleep and depression conditions. Part of the therapy requirements consisted of
monitoring, documenting and discussing the messages and meanings of my dreams. My first
dream while on the medication was so prolific, that I can still remember virtually every detail
to this day. At this time I will try to document the first dream".
"First dream #1:
I was standing approximately 100 yards west of T. Ave. on D. Rd; it was close to 6:00pm,
although I am not sure of the day of the week. The weather was cloudy with overcast. While
standing on the sidewalk I turned my head to the left to witness this vehicle approaching
at a high rate of speed, it was weaving all over the street. As the automobile went by me.
8 Case and Dubey
I can remember looking down at the hand held telephone in my left hand, while doing so I
remember listening to the sound of a horrible crash. I then looked up to survey the area, to
my astonishment neither any other vehicles nor people were anywhere to be seen. I still had
not seen the accident but understood what had happened. In a moment of panic I reached
down and dialed 911 emergency for help. Next I turned around and headed toward a duplex
apartment complex. As I walked up two or three steps I proceeded to the right door entry
way. Upon entering the house I began to look around, there only appeared to be a console
television to my immediate left side, everything else was missing. I then realized that this
was where I lived. I then remember walking through a doorway and walking to my right, there
stood two or three young male individuals acting carefree and somewhat wild in behavior. 1
then remembered asking them if they had seen anyone removing the belongings and furniture
from my place, their reply was that they had not. At that point I began to panic and felt tight
all over my body. I then woke up. I was so relieved and remember feeling melancholy for
hours after."
Personal assessment of dream #1 :
When I was in the 6th grade, I went to live with my father, stepmother and two stepsisters.
They so happened to live in a house located on (see above address). I can remember being
in afraid of my father. I had lived with him once before while going through the 3rd grade. It
was a year to remember. I never knew what to expect of him so I maintained virtually a mode
of fear constantly, never knowing what would set him off.
I have determined that I am the vehicle out of control. The fact that I did not actually witness
the accident represents the uncertainty of my ultimate outcome and that 911 call placed by
myself is me asking for help. The dwelling which I reside in is consistent with virtually every
home that I have lived within during my adult life. The missing furniture represents the loss
in property and money, which I continued to throw away, or spend on prostitutes, drugs or
alcohol. The type of neighbors that lived in the unit next door is reflections of the mentajity
and class of irresponsible people that I surrounded around me during those years."
At the end of this interview, he was given the Booklet version of SIS-II to complete in the office.
This version of the SIS-II was used because of his fragile and potentially violent personality.
While the electronic versions, which use the projective pulling power of hypnotic like floral
scenes can be more powerful, it seemed prudent to avoid the remote risk of disruption
of his fragile mental state. As frequently is observed in examining SIS responses, those
subjectively rated as "liked least", often are of paramount past and persistent body-mind-
spirit significance.
In ranked order of "dislike", he selected the following: B24, B9and B25. Instead of complying
with the printed answer sheet's instructions, he declined to document his reasons for disliking
these on an individual basis. Instead, he categorized his overall negative feelings as follows:
"These pictures were all too similar in their arrangements." This represented psychologically
a defensive maneuver, emotionally distancing him from the projective recollection of his
distressful PTSD memories.
Just like the street address in the dream took him back to his childhood stressful imagery
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