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Childhood trauma is a common although not universal feature of borderline personality disorder (98–104). Recognizing trauma-related aspects of the patient's affective instability, damaged self-image, relationship problems, fears of abandonment, self-injurious behavior, and impulsiveness is important and can facilitate psychotherapy in a variety of ways.

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1. Threats to the therapeutic alliance

Recognizing a trauma history, if present, can help the therapist and patient understand current distortions in the patient's view of self and others as an understandable residual of prior life experiences that would produce mistrust. Anger, impulsiveness, and self-defeating behavior in relationships take on different meanings when understood as, in part, displaced responses to abusive early life experiences. Discounting a trauma history has the potential to undermine the therapeutic alliance and the progress of treatment. It can also hamper patients' ability to integrate and come to terms with the trauma. Not integrating traumatic material into the treatment can lead patients to experience the therapy as a form of collusion with the abuser.

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2. Issues with transference

Many traumatized patients expect others, including their therapists, to be malevolent, for example, inflicting harm in the guise of providing help, analogous to a parent or other caretaker exploiting and abusing a child. This core transference mistrust may become an ongoing issue to be worked on during psychotherapy.

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3. Determining appropriate treatment focus

Decisions about whether and when to focus on trauma, if present, during treatment should be based on the patient's agitation, stability, fragility, evidence of psychotic symptoms, and potential for self-harm or disruption of current vocational, family, or other roles. It is generally thought that working through the residue of trauma is best done at a later phase of treatment, after solidifying the therapeutic alliance, achieving stabilization of symptoms, and establishing an understanding of the patient's history and psychological structures (8).

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4. Working through traumatic memories

In the later phase of treatment, one component of effective psychotherapy for patients with a trauma history involves exposure to, managing affect related to, and cognitively restructuring memories of the traumatic experience. This involves grief work (105), acknowledging, bearing, and putting into perspective the residue of traumatic experiences (106). This process helps to reduce the unbidden, intrusive, and alien nature of traumatic memories and differentiates affect associated with the trauma from that elicited by current relationships.

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5. Importance of group support and therapy

For patients with borderline personality disorder who have experienced trauma, group work can be particularly helpful in providing support and understanding from other trauma survivors as well as a milieu in which they can gain understanding about their self-defeating behaviors and interpersonal relationship patterns. Some patients with borderline personality disorder can be less defensive receiving feedback from peers, and at certain points in therapy this may be the only place they feel understood and safe.

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6. Risk of reenactment or revictimization

The vulnerability of traumatized patients to revictimization, or their deliberate incurring of risk and reenactment of early trauma, has implications for patient safety and management of the transference. The therapist should address the possibility of current or future harm to the patient.

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7. Treating PTSD-like symptoms

Even when full criteria for comorbid PTSD are not present, patients with borderline personality disorder may experience PTSD-like symptoms. For example, symptoms such as intrusion, avoidance, and hyperarousal may emerge during psychotherapy. Awareness of the trauma-related nature of these symptoms can facilitate both psychotherapeutic and pharmacological efforts in symptom relief.

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8. Reassignment of blame

Victims of trauma, especially early in life, typically blame themselves inappropriately for traumatic events over which they had no control (107). This may happen because the trauma was experienced during a developmental period when the child was unable to appreciate independent causation and therefore assumed he or she was responsible. Many adults blame themselves so that they avoid reexperiencing the helplessness associated with trauma. It is important in therapy to listen to a patient's guilt and sense of responsibility for past trauma and, when appropriate, to clarify the patient's lack of responsibility for past trauma as well as the importance of taking responsibility for present life circumstances.

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9. Use of eye movement therapy

Eye movement desensitization and reprocessing (108) has been presented as a treatment for trauma symptoms. It involves having patients discuss a traumatic memory and then move their eyes back and forth rapidly as though they were in rapid eye movement sleep. The specific effect of the eye movements has not been established, and the treatment may mainly involve exposure to and working through trauma-related cognition and affect (109, 110). This therapy is currently under investigation. There is currently no evidence of specific efficacy for this treatment in patients with borderline personality disorder.

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10. Accuracy of distant memories

Ignoring or discounting a trauma history can undermine the therapeutic alliance by aligning the therapist with individuals in the patient's past who either inflicted harm or ignored it. On the other hand, memories of remote traumatic experiences may contain inaccuracies. Dissociative symptoms may complicate retrieval of traumatic memories in patients with borderline personality disorder (111, 112). The affect may be correct even when the details about events are wrong (113). Furthermore, confrontation of family members regarding possible abusive activity is likely to produce substantial emotional response and family disruption. Thus, the approach to traumatic origins of symptoms should be open-ended, sensitive to both the effects of possible trauma and the fallibility of memory.

References

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