For tennis star Destanee Aiava, borderline personality disorder felt like ‘a death sentence’ – and a relief. What is it?

Last week, Australian Open player Destanee Aiava revealed she had struggled with borderline personality disorder.

The tennis player said a formal diagnosis, after suicidal behaviour and severe panic attacks, “was a relief”. But “it also felt like a death sentence because it’s something that I have to live with my whole life”.

A diagnosis is often associated with therapeutic nihilism. This means it’s viewed as impossible to treat, and can leave clinicians and people with the condition in despair.

In fact, people with this disorder can and do recover with adequate support. Understanding it is caused by trauma is fundamental to effectively treat this complex and poorly understood mental illness.

A stigmatising diagnosis

The name “borderline personality disorder” is confusing and adds greatly to the stigma around it.

Doctors first used “borderline” to describe a condition they believed was in-between two others: neurosis and psychosis.

But this implies the condition is not real in itself, and can invalidate the suffering and distress the person and their loved ones experience.

“Personality disorder” is a judgemental term that describes the very essence of a person – their personality – as flawed.

What is borderline personality disorder?

People with the disorder can express a range of symptoms, but high levels of anxiety – including panic attacks – are usually constant.

Symptoms cluster around four main areas:

• high impulsivity (leading to suicidal thoughts and behaviour, self-harm and other risky behaviours)

• unstable or poor sense of self (including low self-esteem)

• mood disturbances (including intense, inappropriate anger, episodic depression or mania)

• problems in relationships.

People with the disorder greatly fear being abandoned and as a result, commonly have distressing difficulties in interpersonal relationships.

This creates a “push-pull” dynamic with loved ones, as people with borderline personality disorder seek closeness, but push away those they love to test the strength of the relationship.

For example, they may escalate a small issue into a major disagreement to see if the loved one will “stick with them” and reinforce their love.

Conversely, if a loved one appears distant or fed up – for example, is thinking about ending the relationship – the person with borderline personality disorder will make major efforts to “pull” them back. This might look like a flurry of messages, expressions of despair, or even suicidal behaviours.

Who does it affect?

The disorder affects one in 100 Australians, although this is likely a conservative estimate, as diagnosis is based on the most severe symptoms.

Women are much more likely to be diagnosed with it than men – but why this is so remains a major debate, with political and sociological factors playing a role in making psychiatric diagnoses. Symptoms usually begin in the mid to late teens.

While an initial response to receiving a diagnosis can be comforting for some, it is commonly seen as a chronic, relapsing condition, meaning symptoms can return after a period of improvement.

Borderline personality disorder can fluctuate in intensity and mimic other conditions such as major depression, bipolar disorder, anxiety disorders and psychosis.

Estimates suggest 26% of presentations at emergency departments for mental health issues are by people diagnosed with personality disorders, particularly borderline personality disorder.

What causes it?

The main cause for borderline personality disorder appears to be trauma in early life, compounded by repeated traumas later.

Early life trauma can lead to biological changes in the brain that cause behavioural, emotional or cognitive shifts, leading to social and relationship issues. This is known as complex post-traumatic stress disorder.

Aiava has acknowledged the disorder is “mainly from childhood trauma”, although she has not given details about her specific experiences.

People with borderline personality disorder usually have complex post-traumatic stress disorder. But complex post-traumatic stress disorder doesn’t always result in a borderline personality disorder diagnosis.

Although the two disorders are not identical, they share many similarities, in particular that they are both caused by complex and repeated trauma.

However those with borderline personality disorder tend to experience more rage, emotional disturbances and have a greater fear of abandonment.

They also face greater stigma, whereas the term “complex post-traumatic stress disorder” doesn’t carry the same negative connotations and focuses on the cause of the condition – trauma – rather than “personality”, leading to better treatment options.

The recognition of the major role of trauma in borderline personality disorder is an important step forward in treating the disorder. But because of the stigma associated with it, using the diagnosis of complex post-traumatic stress disorder maybe a better step forward in the future.

Can it be treated?

There are many effective psychological therapies and other treatments for people with borderline personality disorder or complex post-traumatic stress disorder.

For example, dialectical behavioural therapy is a type of cognitive therapy that helps people learn skills such as tolerating distress, managing relationships, regulating emotions and practising mindfulness.

The treatment of people with post-traumatic stress disorder, including victims of war and rape, has taught us a lot about how to treat complex, underlying trauma. For example, with trauma-focused psychological therapies.

Other new treatments, such as eye movement desensitisation and reprogramming, have also shown to be effective.

Many people with borderline personality disorder who receive treatment and have supportive relationships are able to “outgrow” the condition. Others may need to continue to manage symptoms while pursuing a good quality of life.

Treating trauma, not personality

Rethinking borderline personality disorder as a trauma disorder enables a more effective and understanding approach for those with it.

Understanding what trauma does to the brain means newer, targeted medications can also be used.

For example, our research has shown how the brain’s glutamate system – the chemicals responsible for learning and making sense of one’s environment – is overactive in people with complex post-traumtic stress disorder. Medications that work on the glutumate system may therefore help alleviate borderline personality disorder symptoms.

Educating partners and families about borderline personality disorder, providing them support and co-designing crisis strategies are also important parts of total care. Preventing early life trauma is also critical.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.