Abstract
The advent of the posttraumatic stress disorder diagnosis has been welcomed by many as a recognition of the circumstances and needs of victimized women. This paper argues that the increasing application of the PTSD label to women formerly diagnosed with borderline personality disorder, rather than resolving the dilemmas inherent in use of the borderline diagnosis, has succeeded instead in further medicalizing women's problems and reproducing the previously existing caste system of diagnosis and treatment.
Becker, D. (2000), When She Was Bad: Borderline Personality Disorder in a Posttraumatic Age. American Journal of Orthopsychiatry, 70: 422-432. doi:10.1037/h0087769
Key points
"Designations of normality and pathology owe their origins not only to biological and psychological factors, but also to the sociocultural contexts in which individuals find themselves. The conceptualization of BPD embodied in the DSM-IV (American Psychiatric Association, 1994) continues to reflect a view of women’s problems as inherently intrapsychically derived[...] In contrast, PTSD is one of only a handful of diagnoses in the DSM-IV whose symptoms can be said to stem from situational causes alone. This in itself has rendered PTSD particularly attractive to feminist therapists, who have found in this “non-blaming” diagnosis a means of acknowledging the social/situational origins of certain psychological problems faced by women. On the other hand, the borderline diagnosis, with its overly ample boundaries and unclear applications has acquired an increasingly pejorative connotation. The view of one disorder as a consequence of character and the other as a consequence of fate cannot fail to have significant implications for the narratives of both therapist and client. Today, we might characterize BPD and PTSD as the “bad girl” and the “good girl,” respectively, of psychiatric labels."
"In a study attempting to isolate what they termed markers for BPD, Zanarini, Gunderson, Frankenburg, and Chauncey (1990) identified demandingness entitlement, treatment regressions, and the ability to evoke inappropriate responses in one’s therapist. Use of these behavioral indices as markers for BPD shows us Just how far we can go in accepting a label that stands for an aggregate of behavior as a mental disorder (Kutchins & Kirk, 1997)."
"Circular arguments-- that a person is demanding because she “has” BPD or that a therapist acted inappropriately because her client “has” BPD-- do nothing to advance our understanding of so-called borderline phenomena."
"Although, in the aggregate, several sets of recent studies focusing on the effects of environmental adversity have demonstrated that stress and adversity play an important role in the etiology of some psychiatric disorders, much of the evidence associating environmental stressors with particular dis- orders continues to be indirect, and it is unclear what importance to assign to the role of stress vis-a-vis the course of certain disorders (Dohrenwend, 1998)[...] Any discussion of the relationship between stress and disorder must take into account the social structure within which stressful conditions exist. Such conditions and the options available to us in coping with them are shaped by the sociohistorical context of our lives (Cloward & Piven, 1979). Be cause the classical view of the causal connection between stress and disorder is both persistent and pervasive, as social changes lead to revisions in the prevalence rates and forms of disordered behavior, we will not only continue to uncover new stresses but may see the forms and distribution of disorder change radically even in the absence of equivalent changes in stress (Cloward & Piven)."
"For all the desire to make it so, the normalization of stress responses cannot be accomplished through our fervent attachment to the PTSD diagnosis. Although the diagnosis seems “new” in its uses, those uses reflect the application of the classical stress/disease model to age-old stressors. Reliance on the stress model can have disturbing implications for the representation of women’s experience. There is no single stressful experience in response to which most individuals develop PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Yehuda & McFarlane, 1995). Thus, because PTSD is by no means a universal response to abuse, and because its symptoms are considered involuntary, those symptoms can only exist as the constituents of disease (Lamb, 1996). We cannot, as some have suggested, conceptualize PTSD as a ‘‘normal’’ response to trauma (Hamilton Ce Jens- vold, 1992) and call it a disorder at the same time. Of course, as soon as we name a set of responses to stress “disorder,” we employ science to justify its medicalization. Not only, then, does acceptance of the widespread use of the PTSD diagnosis for women imply acceptance of a reductionistic theoretical framework that subordinates context to individual reaction, but medicalization further separates that reaction into its psychological and biological components[...]
Even where the biology of PTSD is not reified, the dichotomization of the psychological and the environmental persists, as exemplified by Wolfe and Kimerling’s statement that, “Whether a differential vulnerability for PTSD in women relates to underlying or intrinsic characteristics ... as opposed to external factors remains unclear” (p. 202, emphasis added)."
"Zanarini et al. (1998), in studying the pattern of comorbidity of BPD with Axis 1 disorders, found that the symptoms of female borderline inpatients overlapped frequently with those of mood disorders-and with anxiety disorders and eating disorders as well, but not to such an extent. Rather than viewing this comorbidity as proof of how blurred are the boundaries of BPD, the researchers maintained that these comorbid disorders can “mask” an “underlying borderline psychopathology” (p. I733), thereby disguising “true” borderline symptoms. Their solution to this dilemma is to maintain that the extensive comorbidity itself serves as a marker, establishing the uniqueness of the diagnosis by discriminating BPD from other Axis 1 disorders. The fact that 75% of the BPD patients in the study exhibited a certain pattern of comorbidity and 75% of other Axis 1 patients did not was all the evidence these researchers needed to establish the validity of BPD.
This formulation rests upon two erroneous assumptions. One is that the personality disorders are valid categories. Another is that finding what has been put there to find (i.e., finding the affective criteria that have been included in successive revisions of the BPD category by successive DSM committees) and applying those same criteria to inpatients, constitutes proof of the validity of the disorder. This process is akin to that of parents searching for eggs at an Easter hunt; the outcome is certain even if the legitimacy of the enterprise is suspect.
In this same study of 504 inpatients, Zanarini et al. (1998) found that 56% of those with BPD diagnoses also met the criteria for PTSD. Like BPD, PTSD has criteria that overlap with symptoms of affective disorder. Major depression and dysthymia have been shown to be among the features most frequently found to be comorbid with PTSD (Wove & Kimerling, 1997), as well as anxiety symptoms common to social phobia, simple phobia, and panic disorder (Kessler et al., 1995). Research findings indicate that preexisting major depression may increase an individual’s vulnerability to PTSD symptoms following exposure to severe traumatic stress (Resnick, Kifpatrick, Best, & Kramer, 1992). Since symptoms of anxiety and depression are frequently experienced by those diagnosed with both BPD and PTSD, and PTSD, like BPD, is significantly more prevalent among women than among men (Breslau, Davis, Andreski, & Peterson, 1991; Kessler et al., 1995), it may be that the study of the relationships among gender, depression, and anxiety will prove more valuable than current attempts to locate the ever-shifting boundaries between the two diagnoses."
"The linear connection among gender, risk for victimization through traumatic sexual/physical abuse, and BPD or PTSD symptoms fails to take into account that the ways in which individuals express distress (i.e., deviate behaviorally from societal norms) are historically and socially determined. As was noted above, individuals’ experience of stress is shaped by aspects of the sociohistorical context of stress, by their own interpretations of stressful events, and by their evaluations of the options available to them in coping with those events (Cloward & Piven, 1979). Female development implies exposure to sexualization and devaluation in their many guises, regardless of the occurrence of overt abuse (Becker, 1997; Westkott, 1986). There are differences among individuals, however, in the degree and persistence of exposure to stressful events, as well as in their vulnerability to stressors. There are also differences between the sexes in the perception of what is traumatic--that is, in the interpretation of the conditions they face and how symptoms are expressed (Kessler et al., 1995)."
"The trouble with trundling a large group of so- called borderline women off to the shelter of the widening PTSD tent is that it will not serve the purpose of eliminating the borderline diagnosis. It will merely remove those women who have histories of clear-cut traumatic antecedents and PTSD symptomatology from the borderline group, leaving behind a residual group of “true” borderlines. That this is already occurring was made evident by Courtois (1999) in a recent clinical text: The transference projections of interpersonally victimized patients can be very challenging and difficult to manage and are often similar (if not identical) to those identified with personality disturbances. notably borderline personality. (p, / 74) This statement suggests that the “interpersonally victimized patients” and those with “personality disturbances” are not always one and the same. “Borderlines” become a separable group, identified as “difficult to manage.” And the author has unwittingly provided a blueprint for the diagnostic and treatment hierarchy that is now taking shape."
"No amount of fiddling with the present designations, it would seem, will eliminate use of the BPD diagnosis in actual practice. It has not been demonstrated conclusively that clinicians can make this diagnosis with any reliability (Kutchins & Kirk, 1997), and practitioners continue to find interpersonal difficulties-both within and outside the treatment relationship sufficient evidence for the existence of BPD (Kutchins & Kirk, 1997; Walker, 1994). Within the confines of offices, agencies, and institutions, the BPD and PTSD diagnoses are often quite loosely and interchangeably applied by clinicians[...]
Despite the apparent ofthandedness with which both diagnoses are often applied in practice, it is no casual matter for a woman to carry a BPD label. Stefan (1998), in a study of court law, found that women diagnosed with BPD are often considered mentally disabled and, as such, subject to involuntary institutionalization or medication and loss of child custody or parental rights. They likewise are often discredited as witnesses in court cases involving rape or sexual abuse. All of this is in sharp contrast to the way women diagnosed with PTSD are treated. Whereas women who receive diagnoses of PTSD are more likely to benefit under the law on the basis of their disability, women given a BPD diagnosis are not usually thought to be men- tally disabled to the extent that would permit them to receive educational or disability benefits, or to recover damages in an abuse case."
"When the borderline client enters the treatment discussion, however, the client herself and the relationship between therapist and client become the focus, as this statement by Ochberg (1991), in a discussion of a treatment model for PTSD sufferers, illustrates:
Certain coexisting disorders, particularly borderline personality, may be impossible for the posttraumatic therapist to manage according to the principles of PTT. For example, collegiality may be misinterpreted as intimate friendship, and a willingness to intervene with criminal justice may lead to insatiable requests for help with personal affairs. (p. 14)
Again, the term “manage,” with its evocation of nineteenth century “moral management” of the mad (Showalter, 1985) and its reminders of more recent calls for “limit-setting” and “rigid frames” or boundaries in the treatment of individuals with BPD (Reiser (e Levenson, 1984, p. 258) continues to be applied to this subgroup of treatment candidates."
"The therapist’s persistent focus on sexual abuse may be perceived by clients as a demand, both tacit and overt, to focus on this issue, and many women, seeking to be “good,” responsive clients, will not resist this demand. The centralization of trauma in treatment may also put those clients at a disadvantage who cannot be considered either victims of specific abuse or compliant, well-behaved victims. “Borderline” women, many of whom are diagnosed with BPD precisely because they present relational challenges in treatment as elsewhere, may fall into this group."
"It may also be that our continued attachment to the stress paradigm, and to PTSD as its current diagnostic exponent, causes us to fail our women clients in the very task that we had hoped to accomplish, namely, altering the conceptualization of their suffering as a highly individualized phenomenon. It has been this very view that has persistently justified the separation of women’s dis- tress from its sociopolitical contexts on the basis that stress has universal effects on individuals (Kleinman, 1995). Medicalization contributes to the social control of women through expansion of the definition of madness, and leads us in pursuit of cures for the “disease” of PTSD."
Notes from PDV!: This is an article that I find cited in most other articles and studies, and for good reason. There are a couple of points I would gently dispute, or expand upon. The work of Lineham emphasises an adaptive understanding approach to people with BPD, and central to her theory is invalidation--or as we might interpret it over two decades later, insidious emotional abuse. By fixating on sexual/physical abuse as the only "valid" forms of abuse that could shift perspective of BPD from the perspective of pathological personality to trauma responses, she is still approaching trauma from the very male oriented conception of trauma.
"In addition, as abuse increasingly becomes synonymous with trauma, such a large number of symptoms and syndromes is being subsumed under the category “abuse” that the term may eventually lose all meaning (Cushman, 1995)."
I would argue that the ever expanding understanding of events and especially interpersonal harm that can cause traumatic reactions in the person victimised is not weakening the term of "abuse", but instead is ever revealing how profoundly normalised violence is in its various forms, perhaps indicating something about how our society is structured and our social norms are utilised as weapons. Those that push for expansion of the understanding of trauma, of broader understandings of abuse, of violence beyond just physical, are never the people who gain power from the normalisation of such norms.
As for the issue of "true borderlines"--those who are Bad without the history of abuse--my speculation is that these are people with unrecognised austism or ADHD, though I expect many of those who were abused also have autism and ADHD. I personally know several people who have autism and yet are still subject to the BPD label.
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