Cathy was referred to me by her GP for treatment for borderline personality disorder (BPD). She had had a very difficult childhood. Her mother had bipolar disorder and was hospitalised on numerous occasions and her father had difficulties with alcohol abuse, often becoming angry and violent when intoxicated. The pervasive emotion Cathy remembers experiencing was fear.
She was a sensitive child but kept her emotions under wraps to protect her mother and to ensure that she did not incur her father’s wrath. She detached from her feelings and felt “numb” all the time.
In adolescence, this numbness deepened into apathy and sadness and she had her first episode of depression. She was strongly self-critical and started to experience intense social anxiety. She was also sexually assaulted in late adolescence and started avoiding people because she felt as if she couldn’t trust them.
In adulthood, she experienced episodic bouts of depression. She didn’t know how to manage tough emotions and used alcohol and self-harm to numb herself, eventually being diagnosed with BPD. She was preoccupied by thoughts that she was a failure, that she would never get better and that she was going “crazy”.
Cathy had tried dialectical behaviour therapy in the past, a first-line treatment for BPD focused on helping people learn to regulate emotions, manage distress and create better relationships. DBT helped her build distress tolerance skills so she could reduce self-harm and manage her mood better. However, she still felt very sad at times, and continued to struggle with social anxiety and loneliness, as well as recurrent flashbacks to the sexual assault and childhood events.
We initially focused on building a collaborative formulation of Cathy’s difficulties. We spoke about her diagnosis of BPD and realised that it did not encapsulate all the difficulties she had. While Cathy had some of the traits of BPD (emotional regulation difficulties, self-harm and thoughts of death), she did not have difficulties with a lack of identity – a key characteristic of BPD. In fact, she had a strong negative sense of self and a critical inner voice. The difficulty she had with relationships involved avoidance and fear of being judged, not the intense swings between idealisation (“I love you”) and devaluation (“I hate you”) typical of BPD.
We completed some diagnostic measures and a clinical interview and decided that complex post-traumatic stress disorder (C-PTSD) was a better explanation for her difficulties than BPD. Both have overlapping symptoms but are different diagnoses.
C-PTSD occurs when someone is exposed to repeated traumatic events over time. Like PTSD, C-PTSD sufferers experience intrusive memories/flashbacks, avoidance of trauma related stimuli, hypervigilance, and emotional and cognitive changes, such as numbness, anxiety or anger.
C-PTSD also changes how a person views themselves (such as Cathy’s critical inner voice) and how they interact with others (avoidance of closeness). Dissociative experiences (numbing of emotions) is also common. To treat Cathy’s C-PTSD, we needed to use specific trauma treatments, instead of a more general therapy such as DBT or CBT. While emotional management is an important part of C-PTSD therapy it is not the only target, and we usually find that as we engage in specific trauma work, emotional management improves, and self-harm reduces.
Mapping Cathy’s traumas and the core beliefs she formed (“I am defective”) allowed us to process specific traumatic memories and reduce the emotional distress associated with these memories, while forming and strengthening more helpful beliefs (“I am good enough”).
We also encouraged healthy emotional expression, and worked together to help Cathy begin trusting people so she could ask other people for support.
In the later stages of therapy, we used some techniques derived from acceptance and commitment therapy such as values work to assist Cathy with moving toward the life she wanted, instead of simply working to avoid difficult emotions.
Because of the number of traumas Cathy had experienced, this process required almost 18 months of weekly sessions and another year of fortnightly sessions. By the end of treatment, she was able to approach the world with a more positive sense of self. She felt hope for her future and had a range of goals, including a university degree to become a teacher. She had made some friends and was able to tolerate difficult emotions when they arose instead of needing to numb or self-harm. She was accepting of times that felt difficult and had confidence in her capacity to cope, regardless of what life threw at her.
Dr Ahona Guha is a clinical and forensic psychologist, trauma expert, and author from Melbourne. She is the author of Reclaim: Understanding complex trauma and those who abuse, and Life skills for a broken world
Cathy is a fictitious amalgam to exemplify many similar cases
In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, call or text Mental Health America at 988 or chat 988lifeline.org
