Hopefully by now we’ve established what it is that allopregnanolone does. It is an anticonvulsant mood-stabilizer and a GABAergic sedative which until 2020 could only be given in an inpatient setting. It is a controlled substance, which people have naturally circulating in their systems. For people who have trauma, it can be very useful in modulating trauma response. Then, several days out of the month, it goes away (in the case of PME) or it can stop altogether (in the case of menopause). The current FDA approved indication is only for postpartum depression. And then if you take away the allopregnanolone, the ability to be relaxed, control worry, and engage in emotional labor is compromised.
The interaction with trauma is particularly interesting. We usually have this powerful compound available to soothe the nervous system emotionally, in the brain, and throughout the body, and here and there it bottoms out. The usual understanding of bipolar II and borderline personality disorder is you have a normal person occasionally becoming crazy. But what if it’s actually a traumatized person who is sometimes (with the help of allopregnanolone) able to keep it together?
One way of thinking about it is the lid on Pandora’s box. It doesn’t create all the ills that it keeps contained. But just nudge the lid, and everything comes flooding out. A disproportionate number of people with BPD have suffered abuse, and the tendency of people with BPD to utilize CNS depressants (notably alcohol) during flares becomes less mysterious.
Complex Trauma
PTSD was originally applied to soldiers who had survived bombings in a foxhole, or seen comrades blown up in front of them. The current criteria call for a traumatic antecedent, such as first responders and also survivors of sexual assault. If exposure is through media, it clarifies this must be work related (versus entertainment). It can be learning of the death or injuring of a loved one, but must be violent or accidental. The thing is, events of this nature do not cause everyone who experiences them to develop PTSD symptoms.
The ICD-11 includes Complex PTSD (6B41), which includes more domestic violence and childhood abuse antecedents, with 3 additional symptoms of affect regulation problems, decreased self worth, and trouble developing and maintaining relationships. It is not uncommon for people to feel like they can’t have PTSD because others have it worse off than they do. Is it important to distinguish between BPD and Complex PTSD? Strictly speaking the former has preoccupation with real or imagined abandonment which the latter does not. And the latter involves a traumatic antecedent where the former does not.
Pain
I have had pain in parts of my life and spent a couple of years feeling concerned that I was going to have a lot of pain (things with my feet in my late 30’s). I didn’t used to understand my husband’s chronic spine pain until I was in my 50s and had unremitting back pain for 3 months. I might not have recovered from that pain if I weren’t able to invest in good lumbar support. I used to be exasperated at my husband spending hundreds of dollars on particular chairs (that he had experienced at work). But after this back injury in my early 50’s, I did the same thing (somewhat, he has 4 of his special chairs and I only have 1.)
I also have irritable bowel on and off. I don’t think of it as pain, so much as inflammation. I do have DeQuervain’s tenosynovitis, and a lot of my would-be hobbies like yarn crafts, puzzle games, and even feed scrolling should be limited by adequate care of this condition. I suppose if I didn’t also have presbyopia, reading might be added to this list as simply holding a book can aggravate my issues.
One thing I’ve just realized in the last year is I probably have exercise induced asthma, because running makes it hurt to breathe. So I’ve just avoided vigorous aerobic exercise for most of my life. I actually did couch to 5 k on a treadmill, but when the day came for running the 5 k, I found running on inclines triggered the thoracic pain.
Dental pain was often a thing for me, though at this point most of my molars have crowns. But I do have some teeth that have calcified, meaning the root died and I never got attention for it.
I just remember hearing stories about how painful it was to have, say, bone cancer. This was at church, and people were kind of in awe of such suffering. And I developed this deep, mythic fear of chronic pain. I guess that parlays into the fear of burning forever in hell, though this has developed into an understanding of damnation being a matter of regret and loss, which I have suffered anyway due to the death of my first child, and then relative to persecution of my kids who are gender and sexual orientation diverse, and similar crossings of attachment and ideality. (for instance, Ideally the state and country that I have loved wouldn’t erase the identities of my offspring).
But as a psychiatric caregiver, I’m considering pain as an expression of trauma, as opposed to the consequence of a traumatic event (like my husband’s neck pain from a car to bicycle accident he had as a teen). Treatments for pain without a known cause are often anticonvulsant sedatives that have a lot in common with allopregnanolone.
One of the things we may look forward to about menopause is no longer having the suspension of allopregnanolone coincide with the inflammatory processes of menstruation. When I tried to describe PMDD to my abnormal psych professor, she seemed mostly worried about the physical pain of menstrual cramps, which she talked about being hellish. I definitely have cramps, and my last decade of menstruation was characterized by fibroids, but the wanting to be dead, getting in fights, and wondering whether it was merely PMDD or the start of a life altering mood episode was a bigger concern. And this was with my period being relatively regular. For over 25 years before that my periods could vary between 27 and 38 days apart.
Notes:
*Porter C, Palmier-Claus J, Branitsky A, Mansell W, Warwick H, Varese F. Childhood adversity and borderline personality disorder: a meta-analysis. Acta Psychiatr Scand. 2020 Jan;141(1):6-20. doi: 10.1111/acps.13118. Epub 2019 Nov 18. PMID: 31630389.
Neurodivergent Menopause 