Why do Borderline Personality Disorder and Complex Posttraumatic Stress Disorder Get Confused?

The World Health Organization’s 11^th revision of the International Classification of Disease defines Complex Posttraumatic Stress Disorder (CPTSD) as meeting full criteria for PTSD plus symptoms of disturbances in self-organization. Disturbances in self-organization can best be categorized as experiencing strong emotional dysregulation, negative self-concept and poor identity formation, and interpersonal difficulties in the form of intimacy and trust. If that sounds familiar, it’s because it is, and points to a long discussion in the field about the distinctiveness of CPTSD from Borderline Personality Disorder (BPD). Because BPD is also characterized by difficulties in interpersonal relationships, emotional regulation, and self-image (American Psychiatric Association, 2013), the overlap of these two disorders is quite large, making it difficult to discern the two.

CPTSD and BPD’s overlap of symptoms can lead to uncertainty in diagnosis. Distinguishing between these disorders, particularly in individuals with a trauma history, can aid in formulating precise client conceptualization to provide beneficial and accurate treatment (Ford & Courtois, 2014). The focus of and duration of treatment will differ and depend on the distinct symptom profiles of either CPTSD or BPD (Cloitre et al., 2014).

Although they present similarly, the etiology of CPTSD and BPD are different. Trauma is central to the diagnosis of CPTSD; however, while trauma is highly comorbid with BPD, it is not a requirement of the diagnosis (Ford & Courtois, 2014). The most predominant theory behind CPTSD is the role of an inadequate and invalidating family-or-origin environment which contributes to disturbances in self-organization (DSO) as the child fails to receive the transmission of daily skills, emotion regulation strategies, proper reflection of their sense of self, and so on. The DSO combined with the impact of the trauma(s) leads to the unique constellation of complex traumatization symptom presentation (Gold & Ellis, 2017). On the other hand, the prevailing theory of BPD is that of Marsha Linehan’s biosocial theory, which suggests that BPD is a disorder of emotional dysregulation resulting from both biological vulnerabilities and environmental influences (i.e., invalidating childhood environments; 1993).

Differentiating CPTSD and BPD Diagnoses: Self-Concept

Although both disorders are characterized by individuals exhibiting a negative self-concept, individuals with BPD have an unstable sense of self where they alternate between having a grandiose sense of self to quickly possessing a highly negative sense of self (Giourou et al., 2018).

In contrast, individuals with CPTSD do not fluctuate in their self-concept as it stays consistently low, marked by viewing themselves as defeated, worthless, and shameful (Ford & Courtois, 2014; Giourou et al., 2018).

Differentiating CPTSD and BPD Diagnoses: Emotion Dysregulation

Concerning emotional dysregulation, individuals with BPD are impulsive, experience disproportionate distress in response to stressors, and have difficulty distinguishing between reality and their own beliefs (Ford & Courtois, 2014). Furthermore, individuals with BPD are more likely to utilize self-harm or suicidal behaviors to regulate their emotions in comparison to individuals with CPTSD (Powers et al., 2022).

While those with CPTSD also struggle with emotional dysregulation, it is marked by emotional numbing, inability to experience positive emotions, and problems in experiencing and recognizing emotions (Ford & Courtois, 2014).

Differentiating CPTSD and BPD Diagnoses: Interpersonal Relationships

Individuals with BPD often exhibit a disorganized attachment style that fluctuates between extreme idealization to devaluation of others, fear of rejection or abandonment, and the experience of relationships being rapid and intense (Ford & Courtois, 2014; Giourou et al., 2018).

However, individuals with CPTSD are often detached from others, demonstrate an avoidant attachment style, and avoid having close relations with others due to their hypervigilance defense of being harmed and fear of trusting others (Cyr et al., 2022; Ford & Courtois, 2014; Giourou et al., 2018). Another important distinguishing feature is that these interpersonal experiences are stable – unlike BPD in which their interpersonal experiences are transient and alternate between extremes.

Treatment Implications: Why Diagnosis Matters?

The overlap of CPTSD and BPD’s symptoms can lead to diagnostic uncertainty, inaccuracy, or limit the aptitude in which clinicians target individuals’ symptomology. Dialectical Behavioral Therapy can be a useful treatment modality for both disorders, so why is differentiating between these diagnoses being emphasized? Distinguishing between CPTSD and BPD—particularly in individuals with a trauma history—can aid in formulating precise client conceptualization to provide beneficial and accurate treatment (Ford & Courtois, 2014). The focus of and duration of treatment will also differ (Cloitre et al., 2014).

For CPTSD, evidence-based treatments follow the three-phase model pioneered by Herman (1992): establish safety and stabilization (or skills acquisition for emotion regulation), trauma processing, and re-integration into a life worth living. Clinicians must utilize skill-building related to DSO to aid these individuals in developing an identity, regulating their affect, and building secure relationships—which in turn—develops resiliency and a baseline functioning so that trauma processing can begin (Gold & Ellis, 2017).

When working with individuals with BPD, constructs targeted first include life-interfering behaviors (i.e., self-injurious behaviors and suicidality), establishing a stable sense of self, and targeting an individual’s fear of abandonment (Cloitre et al., 2014; Linehan, 1993). Efficacious treatment for individuals with BPD requires a focus on theEir alternating idealization and devaluation in their interpersonal relationships by targeting their affect dysregulation (Ford & Courtois, 2014).

Summary

CPTSD and BPD’s similarities are accompanied by nuanced differences in clients’ self-concepts, interpersonal difficulties, and emotional dysregulation. These differences impact clinicians’ conceptualization and the course of treatment.

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Simona Stoian, MS

Simona Stoian is a 3rd year doctoral-level student at Nova Southeastern University (NSU) working towards her completion of her Doctorate of Psychology. Simona has specialties in psychodynamic theory and serious and persistent mental illness She is currently a practicum student as the South Florida State Hospital, where she treats individuals with serious and persistent mental illness. Her previous practicum placement was at the Psychological Services for the Emotionally Distressed (PSED) at the Psychology Services Center at NSU. She is also the President of the Graduate Psychodynamic Association at NSU.