At midday, I was discharged from an inpatient psychiatric unit, still wearing the hospital socks, an expression of relief and a longing for the comforts of home. The discharge papers read, “diagnosis: major depression recurrent type and borderline personality disorder.”
I was diagnosed with borderline personality disorder (BPD) while an inpatient in summer 2017 and again outpatient in summer 2019, by two different doctors. I also did not experience childhood trauma, including both abuse and neglect.
It is certainly not to downplay the impact and role of early trauma in the development of BPD, which I will highlight. Nevertheless, trauma and abuse did not contribute to my BPD. I am not alone in this experience.
To the 24-hour follow-up outpatient appointment, I wore the same clothes and socks that I had worn upon discharge. I was too tired to change them. “I don’t want to include your BPD diagnosis on this form,” The social worker professed. “It is just from bad parenting.”
Apart from the dismissing usage of the word “just,” her statement held several unhelpful conclusions. “That’s interesting,” I muttered sarcastically, “Given that my mother is also a social worker like you, and I learned about cognitive behavioral therapy from her growing up. I had a great childhood.” She didn’t like that response very much. It challenged her to reconsider the narrow interpretation of BPD.
Highlighted in his book “Borderline Personality Disorder in Adolescents,” BPD expert Dr. Blaise Aguirre notes 12 predominant myths of BPD, two of which particularly address trauma, abuse and family dynamics. Number five reads, “Bad Parenting Causes BPD,” and number 12 reads, “BPD is Caused by Trauma.” In some ways, these assumptions can lead to an interplay of barriers and problems.
Historically, the families of individuals with BPD have been blamed and disparaged by professionals. While devaluation can impact patient reports, early psychology in general developed on the framework that families, particularly mothers, are individually to blame for their child’s mental illness or developmental disorder. Terms such as “refrigerator mother theory” were coined, which declared that autism and schizophrenia are caused by a lack of maternal warmth. Freud’s work also maintained themes of “bad mothers” as the primary source of “neurosis” and “psychosexual problems,” which continued to influence Freudian views for decades.
This “blame culture” may lead to feelings of shame in an already difficult situation and fear to reach out for support. In a study that analyzed the barriers to mental health services for children and young people, fear of negative attitudes toward the parents and feelings of being dismissed or blamed were two of the most common issues.
The fact is some people with BPD are raised in loving and functional families who may have been ill-equipped at responding to mental illness, teaching emotion regulation skills, or in the words of Dr. Aguirre, who “aggravated their child’s underlying vulnerability.”
For example, innate vulnerability to BPD emotional hypersensitivity leads to a tendency to experience heightened negative emotions across various contexts and situations. This vulnerability then makes it difficult to learn and engage in appropriate emotion regulation strategies and impacts behaviors and the perception of the environment, which reinforces the sensitivity. Family members or other people outside the home may then respond in unhelpful ways or trigger reactions. My experience of the environment more closely aligns with this description. Mundane occurrences seemed to immediately incite intense reactions that I struggled to regulate, coupled with self-injury by the time I was 10 years old, sensitivity to perceived slights that could send me spiraling into paranoia, rumination, crying spells, social withdrawal, and what initially appeared to be extreme social anxiety. The dysregulation also impacted my ability to communicate, no matter how supportive the environment, which reinforced my difficulties. Eventually, it developed to more apparent BPD.
When mental health professionals have asked about my childhood, it appears the more I reject the occurrence of trauma, the more inclined they are not to believe me, which they call “denial.” One of my psychologists tried to claim that my awareness of certain events in my life was “hidden from my conscious mind.” Imagine if professionals claimed that you must have experienced childhood trauma and simply do not know it. I have no uncertainties about my childhood memories. Yet, it is a question to them that had only one right answer, and any other answer is evidence for stagnant progress or noncompliance.
Not only are these myths a barrier in the context of treatment, but insisting that my parents were bad parents because I have BPD perpetuates a stigma simply by association with me and my BPD. That is, people may tend to automatically stigmatize my family and people who associate with me simply on the basis that I have BPD. Myths that early trauma/abuse and bad parenting are the only causal factors of BPD invalidate and minimize other experiences of BPD and can encourage blame and gaslighting. They are also misleading.
To address the myth, Aguirre explains that early trauma can indeed further complicate BPD and lead to comorbid post-traumatic stress disorder (PTSD) — yet, he explains at the McLean unit, they also have evidence that reveals up to 50% of the adolescent patients with BPD did not experience some type of trauma.
Dr. John Gunderson highlights in his BPD Brief the importance of recognizing the variability of BPD experiences. He explains 70% of people with BPD in one study experienced sexual and/or physical abuse as a child and 30% did not. Other studies show 40% experienced childhood sexual abuse and 60% did not.
Gunderson also stresses that while people with BPD are more likely than the general population to have experienced some type of childhood trauma, the majority of people who experience trauma in their childhood do not develop BPD. Relatively few people in the general population who experience childhood trauma also develop BPD. He emphasizes early trauma by itself is not explanatory of BPD, nor is it necessary.
Another study revealed that negative affect/intensity was a stronger predictor for the presence of BPD symptoms compared to childhood sexual abuse.
Dr. John Gunderson further describes three main areas of BPD psychopathology (interpersonal relationships, emotion regulation, impulse control) in his video here:
“It used to be thought that these are common problems in the general population that just coincide in some people, but the genetic research has now suggested that there’s a latent inherent coherence to their integrating factor… and something genetically inherent integrates these three, and so it’s not simply the chance occurrence of common phenomena.”
While there is no single “BPD gene,” one twin study of over 5,000 sets of twins identified that 42% of the variation in BPD features was attributable to genetic factors. Another twin study identified BPD had heritability factors of up to 70%. For example, certain heritable factors may result in the vulnerabilities described.
Other studies show brain functioning and structural differences, including but not limited to more reactive amygdala activity. The amygdala plays a key role in processing emotions.
On the other hand, it is also crucial to understand trauma, including abuse and neglect, are common environmental factors that do contribute to BPD. Aside from the studies already described, a meta-analysis that analyzed 97 studies showed BPD was the mental illness most strongly linked to childhood trauma. In other words, people with BPD were more likely to report childhood trauma compared to both the general population and people with other mental illnesses. The study included various types of trauma, including physical and emotional abuse and neglect. It is also important to include that regarding the overall prevalence of trauma, about 30% of people with BPD did not report any of these experiences.
Early trauma is also a transdiagnostic risk factor, which means it heightens the risk to mental illness overall, not just BPD. In fact, more research shows that 54% of the people with BPD did not have PTSD. While further research needs to clarify the overlaps or comorbidity between BPD and other complex post-traumatic presentations, and misdiagnoses may occur, it is clear there are individuals with BPD who did not experience early trauma.
Taken together, BPD develops as a result of the combination of biological, psychological, and early environmental factors. No single experience explains BPD overall, and it is critical to understand and represent the variable experiences and factors. While some people with BPD have extensive environmental factors, including trauma, others might have very little. Treatment may differ depending on these factors. Dialectical behavior therapy (DBT) with trauma-informed approaches may be more effective for people with BPD who have experienced trauma, for instance.
Drawing from the predominant myths, it would make sense that doctors may be reluctant to diagnose BPD when childhood trauma is not present. This assumption may result in misdiagnosis or underdiagnosis in people who have not experienced trauma, which reinforces the belief that trauma is the only cause.
“You aren’t really mentally ill, then!” and “You probably have experienced childhood trauma and just don’t know it!” are a few of the quotes directed at me for years now. I have also witnessed uncountable discourses that state BPD is a trauma response, and trauma response alone. To remove blame and shame from the person with BPD, it appears to be common to emphasize that early trauma/abuse are the only causes. While it is, of course, helpful and important to continue to emphasize someone is not at fault, if BPD and the combination of factors and symptoms were not so stigmatized in ideologies of mental illness in the first place, there would be less pressure to deny it as a mental illness with variable factors, symptoms and experiences. BPD is not my fault, blame or shame either way.
I wrote this article to briefly share the variable experiences of BPD and respond to the gaslighting, invalidation and belittling that I have endured from both professionals and people in the mental health community. In what is supposed to be an accepting and respectful community, many people in the mental health community have shifted to claim mental illnesses overall (particularly BPD) are really because of trauma (apparently the “correct” or “real” way) in order to remove stigma. These claims are not only misleading, but arguing to separate groups for the purpose of decreasing stigma in one group perpetuates stigma and disregard among the other groups, factors and symptoms.
It is stigmatizing and unacceptable to tell people with depression that they shouldn’t be depressed because they have “no reason” to be and “nothing happened to make them that way,” and this inference is generally agreed upon. But for some people, there appears to be a double standard of mental illness regarding these claims and BPD.
I did not experience early loss in the family, early separation from anyone or abuse of any kind. It is not to say I have zero environmental factors or did not experience trauma later as an adult, after my symptoms were quite clear, but I did not experience early trauma that contributed to the development of my BPD. It is just as important to understand that many other people with BPD have experienced early trauma. Experiences are variable. If you’re struggling with BPD, you are not alone, regardless of your experiences.
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