Tuesday, January 12, 2010

Lee Schwecke to psych nurses on misdiagnoses of child victims

Lee reminded me of this editorial she wrote for psychiatric nurses. Note that the most common misdiagnosis is the trash category of craziness in official psychiatric terms: borderline personality disorder (BPD). Lee, I want your voice to be heard by me and everyone who might listen and learn. This is the primary foundation upon which childhood victims and adult survivors' accounts of childhood sexualized violence and terror are dismissed. Lee (lscheck@iupui:

Guest Editorial


Childhood Sexual Abuse,
PTSD, and Borderline
Personality Disorder

Understanding the Connections

Despite years of clinical
teaching and working
part time as a staff nurse
in a psychiatric facility, it took
me a while to see the connections
between childhood traumas
and the adult manifestations of
those traumas in clients diagnosed
with borderline personality
disorder (BPD). It helped that
I had experience working with
veterans diagnosed with posttraumatic
stress disorder (PTSD)
and clients diagnosed with major
depressive disorder who were
survivors of childhood sexual
abuse (CSA). The connections
slowly came together in a series
of textbook chapters about survivors
of violence and trauma (the
latest in Keltner, Schwecke, and
Bostrom [2007]).

As it became more acceptable
to ask psychiatric clients about
their childhood experiences,
CSA was recognized as more
prevalent in America than once
speculated (Keltner et al., 2007).
Actual CSA clients, officially diagnosed
with BPD, contributed
significantly to my learning and
my writings by exploring with
me and clarifying the meanings
underneath their thinking, emotions,
and behaviors. For example,
they shared how self-mutilation
“helps” them manage their
terrible memories, tremendous
emotional pain, and life’s turmoil.
Their dysfunction began to make
sense to me within the context
of their trauma histories. Their
input culminated in a full-page
chart, “Adult Manifestations of
Childhood Sexual Abuse,” in
Keltner et al. (2007). As more
survivors saw this chart and read
my material, they confirmed the
content and developed more insight
into themselves: “I didn’t
realize that all my problems were
coming from the same place”;
“This helps me understand that
I’m not crazy after all.”

My personal belief is that survivors
of CSA are frequently admitted
with incorrect diagnoses,
such as BPD, instead of being recognized
as having PTSD (Table).
Therefore, they do not get the
most appropriate treatment. Survivors
mislabeled as having BPD
may be overmedicated. Their
emotions, needs, and troubling
behaviors tend to be ignored, ridiculed,
or punished. As a result of
not understanding the long-term
effects of abuse and trauma, staff
have difficulty empathizing with
survivors’ intense emotional and
neurobiological symptoms and
only see the dysfunctional surface
symptoms. Staff’s reactions to
“borderlines” may escalate these
clients’ emotions and behaviors.

Approach to Working
with Survivors of CSA

With the assistance of survivors
of CSA, I refined a three-
pronged approach for working
with them in a short hospital stay
of 3 to 5 days. (This “crisis” hospitalization
usually results from
increased thoughts of or attempts
at suicide and/or self-mutilation
and their need to regain control
of their dysfunctional behaviors.)

1. Physical Safety and
Emotional Security

This involves the typical
“no harm” contract and safety
measures. However, I also start
linking their current issues and
behaviors, identified in the admission
interview, to their childhood
abuse/trauma experiences.
This lets clients know that it is a
safe place to discuss the effects of
the trauma(s) on their whole life
and their very being. I do not ask
for details about the trauma, although
some clients want to talk
about what happened to them.
I let them share but do not let
them excessively ruminate.

2. Safe Anger and Anxiety

Guest Editorial

Journal of Psychosocial Nursing • Vol. 47, No. 7, 2009

Clients need to know that
anger and anxiety are normal
human feelings related to abuse/
trauma experiences that can be
expressed safely and appropriately.
Clients are shown how to
use talking strategies, relaxation
techniques, journaling, writing
“letters” to abusers and nonprotectors
(that remain unsent), and
directed anger strategies (e.g.,
talking to a picture of the abuser).

3. Referrals for Outpatient
Services Specifically for CSA

Referrals may be made to
Incest Survivors Anonymous,
groups for rape and incest survivors
(and their partners) through
counseling centers, survivor telephone
lines, crisis and suicide
hotlines, dialectical-behavior
therapy or cognitive-behavioral
therapy groups through mental
health centers, and/or specialized
abuse/trauma counselors.

Road to Recovery

From the time of admission,
I make it clear to survivors that
recovery from CSA and other
traumas is a long, difficult, and
often sporadic process, but that
recovery is possible and worth
it! I find that rehospitalizations
are sometimes needed in crises,
but these tend to be shorter and
less frequent as their recovery
progresses. Survivors develop
more hope as they recognize this


Comparison of Criteria and Symptoms

Criteria for PTSD

Symptoms of CSA

Criteria for BPD

Responses of horror, helplessness, fear

Keeping secrets out of fear of the abuser
and others

Dissociative symptoms—lack of emotions,
numbing, detachment, amnesia

Detachment, disconnection, numbing,
dissociation, amnesia

Transient dissociative

Reexperiencing/reliving the event,
dreams, flashbacks

Intrusive thoughts/memories, nightmares,

Avoidance of or distress with stimuli
related to the trauma, detachment

Memory disturbances and gaps

Addiction issues—alcohol, drugs, spending

Increased arousal, anxiety, startle
response, restlessness, anger

Anger and anxiety issues—holding
anger in, rage, sobbing, increased startle
response, anxiety attacks, inability to relax

Affective instability, rapid
mood shifts

Impairment or distress in functioning—
occupational, social

Control issues—with authority/rules,
being out of control, wanting control,

Transient paranoid symptoms

Relationship issues—lack of trust, fear of
abandonment, dysfunctional interactions

Avoidance of abandonment

Confused sexual identity, lack of sexual
feelings, promiscuity

Unstable and intense

Confused identity, negative self-image

Identity disturbances

Self-punishment—suicide attempts, self-
mutilation, eating disorders

Suicidal and self-mutilation

Body symptoms—vague pains, migraines,
negative/distorted body image

Other—inadequacy, feeling crazy, frozen
emotions, intense guilt and/or shame

Note. BPD = borderline personality disorder; CSA = childhood sexual abuse; PTSD = posttraumatic stress disorder.
Adapted from Keltner, Schwecke, and Bostrom (2007).

Guest Editorial

I hope that my ideas will raise
awareness of the needs of survivors
of childhood abuse and trauma
and improve the psychiatric
nursing services they receive. I
encourage comments from readers
about this subject.


Keltner, N.L., Schwecke, L.H., &
Bostrom, C.E. (2007). Psychiatric
nursing (5th ed.). St. Louis: Mosby/

Lee H. Schwecke, RN, EdD
Indianapolis, Indiana
The author discloses that she has
no significant financial interests in
any product or class of products
discussed directly or indirectly in
this activity, including research support.
[Query #1: Please verify
this statement is correct.]

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