1. Complex Trauma Borderline Personality Disorder and EMDR? Mark McFetridge The Retreat York April 30th 2008

2. You’ll get labelled as a problem penguin if you do If they don’t throw me a fish soon I’m gonna just act normal

3. Borderline Personality Disorder How do you treat BPD? You refer them! (from Herman 1994) “Borderline - the word that strikes terror into the heart of the middle-aged comfort-seeking psychiatrist” (Yalom 1989)

4. CSA and subsequent mental health (USA National Comorbidity Survey) • Significant associations found between CSA and subsequent onset of mood, anxiety, and substance use disorders • In a subsample of respondents reporting no other adversities, odds of depression and substance problems associated with CSA were higher. • Among women, rape (vs molestation), knowing the perpetrator (vs strangers), and chronicity of CSA (vs isolated incidents) were associated with higher odds of some disorders

5. Briere (2005) • Traumatic events intentionally caused by others more likely to produce PTSD • Trauma is necessary but not sufficient to cause dissociation • Trauma moderated by • level of posttraumatic symptoms • affect regulation capacities • Self-Trauma model – exposure within the therapeutic relationship

6. Complex PTSD and Borderline Personality Disorder “The most significant discrepancy between Borderline Personality Disorder and chronic PTSD is the absence in the criteria for BPD of a recognisable stressor in the patient’s history” (Herman, Perry & van der Kolk 1989)

7. Repeated Trauma over time (Complex Trauma) Major disturbances in:- • Affect regulation • Impulse control • Reality testing • Interpersonal relationships • Self-integration

8. Affect regulation and Complex PTSD • Poor affect tolerance • Heightened aggression • Heightened reactivity to mild stimuli • Irritability • Chronic dysphoric mood, emptiness and inner deadness • Recurrent depression

9. Impulse Control and Complex PTSD • Risk-taking behaviour • Self-mutilation (Re-enactments of trauma?) • Drug & alcohol abuse (Defence against the distress of recurrent intrusive memories of trauma?)

10. Reality testing and Complex PTSD Episodic disturbances of:- • Dissociative episodes (re-experiencing peritraumatic depersonalisation, partial BASKing, denigrating voices etc.) • Paranoid ideas of reference (re-experiencing waiting for rejection or violence)

11. Interpersonal relationships and Complex PTSD • Repeated victimisation in adults with CSA Alternating periods of :- • intense searching for closeness with an idealised other • angry/despairing withdrawal & furious denigration of others

12. Self-integration and Complex PTSD • Identity diffusion (self-states/ modes) • Splitting of good and bad self • Relentless sense of inner badness

13. Diagnosing BPD “Having that diagnosis resulted in me getting treated exactly the way I was at home. The minute I got that diagnosis people stopped treating me as though what I was doing had a reason. Good therapists were those who really validated my experience”

14. Alternatively? When survivors recognise the origins of their psychological difficulties in an abusive childhood environment, they no longer need attribute them to to an inherent defect of the self. The way is then open for for a new meaning to experience and a new, unstigmatised identity (Herman 1994)

15. Three stages of therapy for Complex Post-Traumatic Stress(Herman 1994) • Safety • Remembering and mourning • Reconnection

16. The three phases of EMDR for CSA (Parnell 1999) • Beginning : Assessment, preparation and ego strengthening • Middle : Processing and Integration • End : Creativity, Spirituality and Integration

17. Still prefer a nice piece of Mackerel That wasn’t so bad was it?