MHM Magazine

with psychosis) or depression. She became increasingly dissociated, eventually developing five distinct personalities. As we can see in the case study above, contributing to a presentation of emotional dysregulation (which can be diagnosed as bipolar mood disorder or borderline personality disorder) is a history of severe childhood trauma and abandonment. Linda’s childhood was typically an extended period of exposure to abuse and distress. There is a strong suspicion that there is a genetic predisposition to mental health problems, although her father and grandmother were not officially diagnosed. As described above, she never had a secure attachment figure, and was exposed to cumulative trauma. In a case such as Linda’s, the typical signs and symptoms that result from severe, prolonged childhood trauma include: • Intense fear of abandonment. This fear can be real or imagined. These patients are typically highly sensitive to any signs that others might have negative feelings about them. • Unstable and intense relationships. Sometimes, they are in a long-term relationship but can develop a growing feeling that their partner does not love them or wants to leave them. This is based on an unconscious fear of being abandoned, and the anticipation of having a relationship end is difficult to bear. Therefore, they might start a conflict with their partner. • Impulsivity. These patients often act impulsively and cannot explain later why they did certain things that often have negative consequences. The guilt and shame associated with these actions often make them more vulnerable to acting impulsively in the future. • Emotional instability. Unlike in patients with bipolar mood disorder, the mood changes are sudden and in response to a trigger. These patients are often diagnosed with bipolar mood disorder. • Chronic feelings of emptiness and worthlessness. These feelings are complicated to bear. Feeling pain is often more bearable than feeling nothing. • Disturbed sense-image or sense of self. These patients often struggle to know their “true” self. They frequently mimic others they are close to and seem to develop a similar clothing style and behaviour as the people closest to them. • Self-harming behaviours and suicidality. There are many reasons why patients engage in self-harming behaviours, including to feel physical pain rather than emotional pain, to punish themselves, or to get a reaction from their loved ones. Life can be extremely tough to bear, and they might live in a chronic state of suicidality. Sometimes they are ambivalent about being alive or dead but trying to commit suicide is often an impulsive reaction to intolerable distress. • Transient, stress-related paranoia or dissociation. These patients find it challenging to be in their bodies, as their bodies were often subjected to trauma, and being in their own bodies is not experienced as a safe place. They frequently will describe being “outside” their bodies, and they can lose track of what is real and what is not. • Difficulty in trusting others. Many of these patients have never experienced a secure attachment with somebody who will not reject them, and therefore believe no one can be trusted (not to abandon them). Contributing to these signs and symptoms: • Childhood abuse and neglect. This might include a spectrum of severe trauma to “small t” trauma, where there was no apparent abuse, but rather a sense of invalidation from their caregivers. • Early exposure to fear or distress • Parental mental illness or substance abuse • Genetic vulnerability • Attachment disruptions • Cumulative trauma. Due to impulsivity, patients often have numerous traumatic experiences. This reinforces their belief that the world is not a safe place. • Biological changes. Chronic stress alters the brain, particularly in the developing brain. How can we best manage these patients? • Immediate safety is always a top priority. As these patients are chronically at risk for suicide, suicidality should continuously be assessed. Although prolonged hospitalisations are usually not beneficial, patients should be referred to a professional or hospital that can hospitalise them if necessary. • Validation and empathy. Although challenging, these patients do suffer significantly, and it’s essential to validate their suffering. That is only validating what is true (e.g., their distress) and not their perceptions. • Structure and consistency. It’s more important to be consistent than to implement specific “rules.” As implied in the name of the diagnosis, patients with borderline personality disorder struggle to find the borders/boundaries within themselves, which they then project onto their outside world. • Skills for emotional regulation. DBT (dialectical behaviour therapy) is one of the strongest evidence-based treatments for BPD. Emotional regulation and distress tolerance are two of the three DBT modules (the third being interpersonal effectiveness) • Supportive environment. Patients who present in crisis need a supportive environment, which includes a crisis plan and a named “significant other” who can be contacted if the patient needs help. The patient also ideally needs a mental MHM | 2025 | Volume 12 | Issue 3 | Addressing the needs of patients with BPD (borderline personality disorder) and childhood trauma MHM 12 | MENTAL HEALTH MATTERS | 2025 | I ue 3 H