This can be difficult to determine as both BPD and CPTSD can look similar. And to complicate it even more. Complex Post Traumatic Stress Disorder or (CPTSD) is not yet recognized in the Diagnostic and Statistical Manual of Mental Disorders or DSM. In contrast, Borderline Personality Disorder or BPD is recognized in the DSM.
This is not going to be a brief article on these two similar yet different disorders.
I hope that this will feel like a reasonably comprehensive article.
So if you are here for you or a friend or a loved one, I hope you feel more confident about what BPD and CPTSD are by the time you are finished reading.
That if you feel like you may need help with either of these, you feel more confident to seek the services of a licensed mental health professional in your area and know what you need help with. And if you are not able to seek out services in your area then I want to share with you an alternative resource and that is Therapy-Online.com and you can use my link to receive a 20% discount [affiliate link]. It’s my belief that everyone should be able to have access to mental health resources and if you feel that you would benefit from therapy then I encourage you to give it a try.
Or, if a friend or loved one is struggling, you feel more confident in encouraging them to get the services they need. And possibly a second opinion if they are being treated for the wrong diagnosis. And of course, you are always welcome to share my Therapy-Online.com resource with them [affiliate link].
Let’s start with what BPD and CPTSD look like before we delve into the differences between the two.
What is Borderline Personality Disorder or BPD
Borderline Personality Disorder (BPD) is a psychoanalytic term going back to the early years of mental health and was coined by Psychoanalyst Adolph Stern.
It was called this because it was believed to be on the border of psychosis and neurosis. Neurosis meaning sadness and inability to regulate emotions. And psychosis meaning the paranoia or disassociation that can sometimes be seen in BPD when that person is under extreme forms of stress.
Ultimately this is a pervasive disorder of affect and interpersonal instability that can be seen throughout a person’s life. And must meet 5 of the nine diagnostic criteria needed to qualify for the diagnosis. An important note is that it must also be affecting your life. If it is not affecting your life, then you don’t get the diagnosis.
Risk Factors for BPD
This is where the nature vs. nurture argument comes in. But studies are showing that it seems to be a bit of both. There is a hereditability factor that is being explored in studies. And people have an increased risk factor for developing BPD if a first-degree genetic relative is diagnosed with BPD. Studies show that those with a first-degree genetic relative (mom, dad, and siblings) are ten times more likely to develop BPD.
But before you take this information and run, keep in mind, the BPD population is somewhere around 1.6% – 5.9% according to the DSM 5. So, being 10x more likely is somewhere in the ballpark of 14.1%, according to a study published in Molecular Psychiatry in 2019.
This is where we get into the nurture part. Traumatic life events, such as sexual or physical abuse, neglect, and parental divorce or illness (also known as complex traumas), are more frequently reported by those diagnosed with BPD when compared to those without a mental health diagnosis or other personality disorder.
However, experiencing a traumatic event is not part of the diagnostic criteria for a BPD diagnosis.
This means that you can receive a diagnosis of BPD and never once experience a trauma. Therefore, the heritability portion is estimated at 46%, with the remaining 54% as environmental factors such as abuse/trauma and toxic environments.
Environmental Factors
According to the research, 54% of the risk of developing BPD is attributed to environmental factors such as:
- Being a victim of forms of interpersonal trauma. Such as emotional abuse, physical abuse, or sexual abuse.
- Exposed to long-term fear or distress as a child (not being shown how to self-soothe or emotionally regulate).
- Being neglected by primary caregivers. Growing up in an invalidating early environment the majority of the time can create the setup for believing that all environments will be this way.
- Or growing up in a home with a caregiver who struggled with their own mental illness or substance use led to an unstable environment.
However, not everyone who has BPD has had these types of childhood experiences. Although a large number have, and not everyone who has had these experiences will go on to develop BPD.
Those who grow up in invalidating environments don’t always develop BPD, and the same can be said for those who grow up in a validating environment can develop BPD.
And that may be the biological vulnerability component that is still being researched.
Biological Vulnerability
According to research, it is estimated that 46% of the risk of developing BPD is inherited. There is still a lot of research in this area, but abnormal functioning of the Amygdala where emotional regulation has been found and has been seen in studies of individuals with BPD.
This could be expected to be seen in those with BPD if they were raised in environments with caregivers that were not responsive to their needs.
The Amygdala is where the “fight or flight” response is housed and plays a pivotal role in emotional remembrances.
Things that have strong emotions tied to them, whether they are good emotions or bad emotions, are likely to be the things that have allowed them to survive in their environment.
This includes the detection of threat and activation of appropriate fear-related behaviors to perceived threatening or dangerous stimuli.
It has also been noted that those with BPD also have more reactive fronto-limbic neural networks. To explain this more simply, those with BPD have been shown to have more reactive Amygdala and fronto-limbic neural networks, which means that they can tap into these pathways more quickly and intensely than their non-BPD counterparts.
Here is the good news. Neuro-plasticity is a thing, which means that if you have BPD and are tapping into these pathways too quickly. You can learn how to re-wire your brain to tap into them more slowly and develop better affective (emotional) regulation. It does take time and conscious effort, but it can be done by learning other skills to regulate or delay the reactivity.
Marsha Linehan created Dialectical Behavioral Therapy [affiliate link] and pioneered the treatment standards for those with BPD. And has a ton of resources that can help those with BPD develop these skills.
If you’re interested, check out her DBT Workbook [affiliate link]. I have used this workbook more times than I could ever count working with my people that struggle with BPD to gain the skills they need to change their lives.
The DSM-5 Diagnostic Criteria of BPD
The DSM-5 lists the nine diagnostic criteria that make up the BPD diagnosis. And the diagnostic criteria must be present and seen in various contexts no later than early adulthood (early 20’s). This means that you cannot wake up at 35 years old and start meeting the diagnostic criteria. It must have been present no later than the early adult years. However, there were some signs of it in their teen years for most people with this diagnosis.
Does this mean that a teen can be given a BPD diagnosis? The answer is yes, but it should be done with great caution in the teen years because some of the diagnostic criteria can be expected to be seen in the teen years to a degree. There is also the argument that hormonal fluctuations and how they impact mood and personality development are still developing during the teen years. Yet another reason this diagnosis should be given with extreme caution.
So, if you are a parent and wondering if your teen has BPD, it is possible. I recommend consulting with a licensed mental health professional and even getting a second opinion.
What are the Diagnostic Criteria
Understanding what BPD is and how it differs from CPTSD helps to understand the diagnostic criteria.
1.) Frantic efforts to avoid abandonment regardless of whether it is real or perceived (imagined). These frantic efforts can look like panic, anger, or fury. These responses are viewed to be outside of the norm (hence the caution when it comes to teenagers) and may attribute the “abandonment” to they are “bad.”
An example of this can be a simple argument. And a person who meets this diagnostic criterion believes that the argument equals that person will leave them. As a result, they respond with intense panic, anger, or fury. And by preparing for this perceived abandonment, they (unknowingly) grind the other person into the ground, which can become a self-fulfilling prophecy.
2.) Intense, unstable relationships alternating between idealization and devaluation – Wanting to be around that person 24/7. And then rapidly shift to feeling like that person isn’t “there” enough for them (again, a word of caution regarding teenagers).
This can be a relationship with intense passion followed by intense anger and feels much like a rollercoaster. This diagnostic criterion is not limited to just intimate relationships. But it can also apply to friends, family, coworkers, etc., and can be pervasive across multiple types of relationships.
3.) Identity disturbance – Almost literally not knowing who they are, the “who am I” (again, a word of caution with teenagers).
And is seen as sudden and dramatic shifts in self-image, shifting goals, values, aspirations, sexual identity, and friends in their attempt to figure out who they are.
In some instances, a person with BPD may change their name and, in extreme cases, their personality (i.e., baby person to sexy person) from one day to the next. To the point where it can look like Dissociative Identity Disorder (DID).
And the people in their life never know who they may be interacting with from one encounter to the next.
4.) Impulsivity – acting out and behaving in a way w/o thinking about it. This can be seen as substance use, binge eating, gambling, unsafe sex, or spending money recklessly.
For some people with BPD, this is an attempt to self-soothe their mood but is not addressing the problem. It’s essentially “I don’t want to feel this way, so I’m going to go do (x),” and in the short-term, they do feel better. But oftentimes at a much higher cost.
This diagnostic criterion, especially, gets confused with Bipolar Disorder or BP. Because this is seen in Bipolar Disorder, but its life cycle looks very different. For a person with BPD, this all happens very quickly and regulates emotions and even possibly identity disturbance. Whereas with Bipolar, this impulsivity is seen over the span of many days, typically four or more days and not over moments of time.
5.) And probably the most well-known is suicidal ideation or behaviors and self-harming and afflicts about 52% of those with BPD. Because of this, there is a high rate of suicide attempts and typically occur when the person with BPD feels a sense of abandonment. And can be used to draw the other person back to keep them safe.
Sometimes this can look like the person with BPD calling that person while self-harming or having consumed something toxic to get the other to come to their side and no longer feel abandoned.
Self-harming is a response to inner pain and is not limited to just cutting or burning. But are self-destructive acts and can include withholding food, water, medications, or anything else that can be viewed as self-destructive.
Approximately 8-10% of those with BPD will die by suicide, and some of those suicides are accidental.
6.) Affective instability or negative affect, meaning moods are all over the place and sometimes even in just a few hours. Moods shift and fluctuate in a short period of time and act in line with their emotion, and the person with BPD cannot inhibit it.
For example, if they feel angry, they express that feeling strongly and show it to others. And if their moods are all up and down, their relationships, as a result, would also be all over the place—those with BPD experience hyperreactivity to what Is happening in their environment. (A word of caution with teenagers. Moods are impacted by hormones and the teen years are the years where there is a large influx of hormones).
Again, this is most often misdiagnosed as Bipolar Disorder. The big difference is that those with BPD can be all over the map mood-wise over a few hours and rarely for more than a day or two. In contrast, those with Bipolar Disorder will experience affective instability for days to possibly a week or more.
7.) Chronic feelings of emptiness can be described as feeling like a hollow shell or drum. So naturally, a person with BPD will want to fill up that empty or hollow feeling. And many choose to do it through other people (hence why abandonment feels so terrifying) or other inappropriate ways.
This may be through shopping, substance use, or other impulsive acts that can bring short-term relief.
This sense of emptiness may also be part of the third criteria – an unstable sense of self. If I don’t know who I am and look to those outside of me to tell me who I am. Then when I feel empty, I’m going to look to the outside world to fill me up because I don’t know who I am. And I can’t fill myself up. This can be a panic-inducing feeling for a person with BPD. Again, not knowing who they are and feeling empty inside.
8.) Inappropriate and intense shows of anger and small things will blow up into something much more significant and out of proportion.
A person with BPD may become physically combative.
They may express anger through screaming and yelling, and it happens so quickly and intensely that it sometimes scares other people.
Others may feel like they’re walking on eggshells out of fear of the next explosion.
People with BPD feel everything and over-feel it (highly sensitive) and will react with anger. Those with BPD may feel regretful or terrified that people will abandon them after their intense show of rage.
Again, possibly creating that self-fulfilling prophecy around abandonment, and then they get angry at themselves or fearful of abandonment and may turn to self-harm to cope.
9.) Paranoia or dissociative symptoms. Under significant stress, those with BPD can develop psychosis-like symptoms. And may feel paranoid, hear negative voices and look like they’re delusional.
These voices may sometimes sound like – I hear my mother’s voice, “she hates me.” Or I know others are out to get me. Symptoms of disassociation can occur. Such as an adult, acting and behaving like a child can look like Dissociative Identity Disorder under severe enough stress.
Please note – IF IT IS NOT AFFECTING YOUR LIFE, THEN YOU DON’T GET THE DIAGNOSIS.
Splitting
Splitting can be a defense mechanism and a phenomenon where there is all good or bad or black-and-white thinking. It can be about people, situations, or even themselves. And may look like the greatest thing since sliced bread one moment and into the trash heap or under the bus the next moment.
However, splitting can also serve as a defense mechanism when a person experiences childhood trauma. For example, if a caregiver was their abuser, splitting can help the person with BPD by “splitting” that person into the ‘good safe’ version of that person and the ‘bad not safe’ version of that person.
It would be difficult for a kiddo to reconcile that into a whole person that their caregiver is capable of being both good and bad. So splitting, in this case, would make sense. It is experiencing one person as two completely different people.
The subtypes of BPD
Psychologist Dr. Theodore Millon coined the four subtypes of BPD. And while they are not recognized (at this time) in the DSM-5, there is enough empirical research to support their existence.
Dr. Millon is one of the leading experts in the field of personality disorders. And most specifically in Borderline Personality Disorder, so he knows what he’s talking about.
The difficulty with subtypes or with diagnosis, in general, is they are not necessarily easy to diagnose even for the most seasoned of mental health professionals. And can take weeks or months of seeing a person before a mental health professional feels confident with what they suspect may be going on.
High-Functioning BPD or “Quiet” BPD
Those with the most dramatic, “externalized” BPD symptoms, such as violent behaviors or suicidality, are prioritized within the mental health system. These are the folks that catch the attention of the mental health system and are essentially put through the express lane to get services.
Those with high-functioning BPD may not demonstrate the dramatic and externalized symptoms of BPD and, as a result, are overlooked. These are the folks that may come in for services and are told that they do not meet the criteria for services because, on the outside, they look pretty functional. But on the inside may be struggling with feelings of unworthiness. And then when they’re told that they don’t meet criteria for services reinforces this belief and, as a result, may feel guilty for reaching out, and other people “should” be a priority over themselves.
Again, the research states that most people who suffer from BPD will have experienced trauma, most typically in their childhood. However, for the high-functioning BPD, this trauma may be more complex trauma and is more invisible and insidious in nature. This could look like being emotionally abused, chronically neglected, surviving a dysfunctional family, or parentified.
Split Psyche
Sometimes what results in the high-functioning BPD is a split in their psyche. A part of your psyche is given the task to carry and contain the overwhelming trauma. At the same time, the rest is tasked with carrying on with life as usual and keeping up appearances.
For some, this may feel like a younger part of you trapped and living in the body of an adult. For the high-functioning BPD, they may feel like a 15-year-old trapped in the body of an adult, tasked to function as an adult and keep up appearances. But may act or respond like a 15-year-old when emotionally triggered or during times of extreme stress. And are left feeling overwhelmed, out of their depth, and grasping for survival in a world that this part of the psyche is not old enough to navigate.
However, the other part becomes “over-developed,” leaps into adulthood, and marches on with life. This is most commonly seen in the high-functioning BPD that was parentified. They are highly responsible and grown-up, learning early on that they can’t count on others. And this is the part of the high-functioning BPD that society sees.
But behind closed doors, the high-functioning BPD may be struggling with co-occurring anxiety, depression, addiction, and compulsive tendencies. When left alone for too long or when the high-functioning BPD lets their guard down, anger or rage occurs. This is, in essence, the rage and fury of the high-functioning BPD’s inner child that was tasked to carry and contain the overwhelming trauma. And it is not until the walls come crashing down around this part of the psyche that people glimpse the turmoil inside the high-functioning BPD.
The high-functioning BPD internalizes and talk to themselves harshly (self-harming self-talk) and believe that the world would be better off without them. As a result, they have tremendous difficulty tolerating stress and will quickly rage quietly at themselves and may self-harm in different, less noticeable ways, such as starving themselves.
Because of their ability to function, high-functioning BPD’s typically have professional careers and may work as teachers, medical professionals, or mental health professionals.
The Petulant BPD
This subtype is more externalizing than the high-functioning subtype. And is more attention-seeking and emotionally dysregulated.
The petulant BPD can come across as more irritable, complaining, stubborn, and pessimistic. This subtype may view themselves as unable to get better and may identify as “I am borderline.” Instead of seeing it as something that can be overcome.
The petulant BPD is often torn between relying on others and keeping their distance out of fear of disappointment and fears of abandonment. And may switch between feelings of unworthiness of connection with others and anger that can be explosive.
This subtype may quickly feel insulted and react in defiant and stubborn ways to perceived slights. There is almost a sense of entitlement with the petulant BPD that they will get their way. And may even go as far as throwing a tantrum to get it. And not a tantrum in the sense of “haha, I got my way,” but in the sense of “I can’t tolerate the disappointment if I don’t.”
This pattern may be seen as socially immature and may be viewed as acting out if they don’t get their way.
The petulant BPD may not recognize their anger as theirs to own but may blame others and the world for it that it isn’t their problem but the problem of others.
They may also have difficulty healthily expressing their needs and may be passive-aggressive in relationships of “If you really loved me, then you would know what I want.”
This subtype can sometimes be difficult to distinguish because it has some considerable overlap with Narcissistic Personality Disorder.
The Angry Externalizing Impulsive BPD
This subtype is also externalizing and is in almost constant conflict with society. As a result, bouts of violence are not uncommon. And this subtype does not think before acting, and because of this, their environment is chaotic. This may be due to feeling like those around them deserve to be punished for the pain that the angry externalizing impulsive BPD is experiencing and behaves accordingly.
On the other extreme, this subtype may also seek approval at any cost. And is sometimes referred to as the first cousin to the Histrionic Personality Disorder. Because this subtype can be flirtatious, captivating, elusive, and superficial, they tend to be highly energetic and thrill-seeking. Conversely, they are easily bored and have an insatiable appetite for attention and excitement.
However, unlike Histrionic Personality Disorder, that is visibly uncomfortable when they are not the center of attention. This subtype is triggered by fears of disappointment or abandonment and will use this superficial attention-seeking style to stop abandonment.
The Depressive Internalizing (self-defeating/self-destructive) BPD
Unlike the high-functioning subtype, this is a depressive type. This subtype may not be able to secure employment because of the depressive undercurrents. And it may be difficult for this subtype to find the energy for sustainable employment.
Depressive symptoms are more exacerbated around disappointment, frustration, and fears of abandonment which puts this subtype at a higher risk of self-harm and suicide. Because of this, depression becomes the focus of treatment.
Dysregulated instability can make the lows of depression even lower when facing a crisis and may need more support and help. As a result, this subtype may isolate more and have fewer supports in their life. In addition, because depression is such a core feature, it may make it harder for them to remain functioning globally and have passive thoughts of ‘why am I here.
Because of the severity of the depression, this subtype may be more impulsive and indecisive. And may vacillate between apologizing and submissive to stubborn resistance and harbor a lot of self-hatred.
When this subtype reaches out or comes in contact with mental health services, their depression may become the focus of treatment. And the BPD may go unnoticed or be placed as secondary to be addressed after their depression has been stabilized.
Common co-occurring disorders
It’s estimated that for those diagnosed with BPD, 95.7% will have at least one co-occurring disorder. The most common is PTSD at 76.0%, anxiety disorders at 75.7%, affective disorders at 76.0%, and substance use disorders at 48.6%.
How the family system can support someone with BPD
It can be very hard on a family that has a loved one that is struggling with BPD. Family members often feel helpless and do not know how to support their loved ones. This may be particularly true for parents, caregivers, and spouses.
The hyper-monitoring can feel like walking on eggshells and can exhaust the family. “When is the next blow up?” or “I don’t know what to say or not to say” and causes anxiety with not knowing what to do and its impact. Then there is confusion and a sense of helplessness, we don’t know what to say or do, and the family may feel like they are enabling out of fear of a blow-up.
Communication in families can be catastrophic when miscommunication occurs. For example, passive-aggressive or sarcastic tones can be misinterpreted and can escalate into a much larger argument.
The tone in how things are said and in how it’s delivered does matter in how things are communicated. And being mindful of this can prevent miscommunication and avert a possible blow-up.
Awareness of abandonment is a key theme. Such as abruptly leaving a room while in an argument. And awareness around psychological distance in a space. Those with BPD are acutely aware of the temperature in the room.
A person pulling back a bit can be perceived as abandonment. So make sure you set it up and let them know that you need to take a moment. It’s essential to communicate when you need to take a break. As well as where you can be found and that you will return once you are done taking that time.
The Myth of BPD
There is a myth surrounding BPD and men. And I want to take a moment and address that myth now. The myth is that BPD predominately affects women, and the DSM-5 states that 75% of those with BPD are females. And that men are rarely seen to have BPD. In the mental health field, these ‘rare’ males can sometimes be referred to as the ‘rare male BPD.’ I believe this is a myth for a few reasons.
And the biggest one may be due to how boys are socialized to express emotion.
Our culture encourages boys not to show emotions unless those emotions are anger or rage. And everything else, they need to just “suck it up” and put their feelings into a box. And if you have ever read Brene’ Brown’s book Daring Greatly [affiliate link], she talks about the culture of shame and vulnerability with men and boys.
I believe that because of this conditioning and the bias that BPD is a predominately female disorder.
Males are more likely to be misdiagnosed and given an impulse control disorder or other personality disorders.
For instance, Antisocial Personality Disorder, which according to the DSM-5, affects men predominately.
Or Narcissistic Personality Disorder with males making up anywhere from 50%-75% of this diagnosis.
I find it ironic that these two personality disorders are believed to affect men predominately. And again may be due to how our culture socializes boys and men to express emotions.
What is Complex Post Traumatic Stress Disorder or CPTSD
Complex Post Traumatic Stress Disorder or CPTSD is recognized in the ICD 11 (International Classification of Diseases) but not the DSM 5 (Diagnostic and Statistical Manual of Mental Disorders). However, it is becoming more widely recognized and may be added in future revisions of the DSM.
There is a lot of research going on to show that CPTSD is unique from PTSD. And that CPTSD may be a more appropriate diagnosis than BPD or BPD with co-occurring PTSD for others.
CPTSD is prolonged, repeated, or repetitive trauma and is different from PTSD, which can be acute (brief) or episodic, meaning one trauma is all that is needed.
CPTSD consists of the same symptoms of PTSD with three additional criteria that can look similar to BPD. Those symptoms are emotional dysregulation, negative self-cognitions, and interpersonal hardships. This is what makes differentiating CPTSD from BPD so very difficult. Unfortunately, these three criteria resemble the clinical features commonly associated with BPD. And may be why those with BPD sometimes receive a co-occurring diagnosis of PTSD instead of a diagnosis of CPTSD.
Risk Factors for CPTSD
Any type of severe interpersonal trauma, long-term trauma, or series of traumatic events occurring over the course of many months or years. And occurs when a person fears for their safety or the safety of another. With CPTSD, the trauma that a person experiences is typically interpersonal in nature. And can be anything from childhood abuse (sexual, physical, mental, psychological), neglect, or intimate partner violence, to name a common few. And the person experiencing the abuse loses a sense of safety and trust in others. This may be due to the nature of the traumas and the feeling that escape is impossible or very difficult to achieve. The traumas experienced do not have to be the same trauma but can be other different traumas.
Research shows that CPTSD seems to appear more frequently in people who have been abused by someone who was supposed to be their caregiver (parent/guardian) or protector. However, the risk of developing CPTSD is not just for the young. Adulthood trauma such as sexual assault can lead to CPTSD even after a person’s personality has been developed.
Typically when this occurs, the person that has experienced CPTSD experiences a significant change in their personality. Such as emotional dysregulation, negative self-concept (self-image), and interpersonal problems. The same three criteria would be seen with someone who has CPTSD after experiencing childhood traumas.
Environmental Factors
CPTSD is caused by prolonged, repeated, or repetitive trauma in a person’s life that is experienced or witnessed. And is experienced as extremely threatening to their safety or life and from which escape is difficult or impossible.
Such as being a victim of emotional, physical, or sexual abuse or neglect. Resulting in long-term fear or distress as a child.
Or growing up in a home with a caregiver who struggled with their own mental illness or substance use led to an unstable and dangerous environment.
Living in a home with domestic violence or in a dangerous neighborhood where violence occurs.
Other examples are torture, slavery, genocide campaigns, or experiencing what is now referred to as intimate partner violence.
CPTSD does not occur just solely from just one trauma happening of a prolonged or repetitive nature. But can also occur when a person experiences multiple traumas in nature.
However, not everyone who has experienced these environments will develop CPTSD. Although many have, and we know this because of the ACE survey, and I will talk more on this further down.
If you have read through the BPD environmental factors, you may have noticed considerable overlap. This is because the same environments that increase the risk for BPD are the same environments that increase the risk for CPTSD.
Biological Vulnerability
A UCLA-led study completed in 2016 analyzed 142 women and looked at how chronic stress affects new parents and their babies. What was determined is that women even before pregnancy with elevated cortisol (stress hormone) patterns are likelier to give birth to lower-weight babies. This is because elevated cortisol levels outside of the norm reduce blood flow to the fetus. And when this stress hormone is elevated over long periods of time will influence the baby’s growth, development, and the child’s response to stress later in life.
Another study completed in 2020 at the University of Edinburgh took hair samples from 78 pregnant women to determine their cortisol levels in the previous 3 months. The babies of these women underwent a series of brain scans while they slept. Researchers found that higher cortisol levels in the mother’s hair were linked to structural changes in the infants’ amygdala and differences in brain connections. These changes could contribute to emotional issues in later life.
The amygdala is also part of the fronto-limbic network where emotion regulation and “fight, flight, and freeze” responses are housed. Unfortunately, the amygdala of children who have experienced CPTSD and the bombardment of cortisol can be smaller as much as 20% or more by the time they reach adulthood.
Further studies have been done with veterans diagnosed with PTSD, and structural changes and responses have been seen in this population compared to those without PTSD. It’s interesting to note that those veterans that qualify for a PTSD diagnosis about 25%-50% also meet the criteria for CPTSD.
So, what does all of this mean? First, it means that if your mom before or during her pregnancy with you experienced high levels of stress or trauma over an extended period of time, you might have a biological vulnerability. Second, it also means that if you are born into an environment that is dangerous or neglectful, your brain can undergo structural changes. Finally, it also means that if you are an adult and experience trauma, especially ongoing, repeated trauma, or many traumas. Your brain can also undergo structural changes.
You may have noticed that some overlap here with BPD biological vulnerability and the areas of the brain that are impacted. This is because the environments that can cause BPD can cause CPTSD are similar in nature and ultimately cause changes in the brain.
The Adverse Childhood Experiences Survey
The ACEs study was completed between 1995-1997 and involved just over 17,000 participants. Its focus was on how negative adverse childhood experiences (traumas) impacted those children in adulthood.
The results of this study brought to light groundbreaking insights that were not expected. The first was, childhood trauma is more common than previously thought. The other is the prevalence of childhood trauma is not limited to race, creed, or income. Instead, it cuts across all populations regardless of income, religion, race, and education.
From the 17,337 adults that participated in the study, it was learned that 1 in 6 men and 1 in 4 women reported sexual abuse before their 18th birthday.
It was also discovered that the ten different categories that were being researched (abuse, neglect, and other household stressors) rarely occurred as just one single event. Meaning these adults reported multiple forms of trauma that were experienced in childhood.
Of those that reported sexual abuse in childhood, 80% reported at least one other form of abuse perpetrated against them during their childhoods.
In addition to these discoveries have been the correlation between high ACE scores and higher physical health and mental health issues.
This list is by no means all-inclusive, but these are some of the more common issues seen in adults with high ACE scores.
· Substance use (alcohol, tobacco, and other substances)
· Depression
· Heart Disease
· Poor work performance leading to loss of jobs
· Impaired interpersonal relationships
· Increased risk of intimate partner violence (perpetrator or perpetrated against)
· Numerous sexual partners (increased risk of STD)
· Suicide attempts and completed suicides
· Eating Disorders
· The development of BPD, Dissociative Identity Disorder, and other serious mental health problems.
ICD 11 Diagnostic Criteria for CPTSD
To meet the criteria for CPTSD, you must first meet the criteria for PTSD. The following symptoms have been present for several weeks after experiencing a trauma. And causing significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.
Re-experiencing type symptoms:
· Flashbacks, i.e., reliving the trauma over and over, including physical symptoms like a racing heart or sweating.
· Nightmares – in children, this can look like frightening dreams without recognizable content.
· Strong overwhelming emotions of fear or horror paired with strong physical sensations.
The re-experiencing symptoms are often triggered by reminders of the trauma. And can consist of people, places, things, smells, or even the person’s own thoughts can trigger a trauma memory. Once triggered, the person can feel like they are re-living the event.
Avoidance type symptoms:
Avoiding people, places, events, or objects that are reminders of the experience. And can include thoughts or feelings related to the traumatic event.
Avoidance symptoms can cause a person to isolate themselves to avoid someone who may trigger them. Or to stay away from geographic locations or other similar locations where a traumatic event occurred.
Arousal and reactivity type symptoms:
· Hyper-vigilance can be described as an enhanced startle response (fight, flight, or freeze) to unexpected noises or things that appear to be dangerous.
· Feeling tense or “on edge.”
· Having difficulty sleeping, staying asleep, and/or having angry outbursts.
In addition to needing to meet all of the diagnostic criteria for PTSD, Complex PTSD requires additional layers of severe and persistent symptoms. And cause significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.
Symptoms of CPTSD include:
· Problems with affect (emotion or mood) regulation.
Survivors can find that they have a challenging time experiencing, expressing, and controlling their emotions and can become overwhelmed by their emotions. Dissociation can occur when survivors are overwhelmed by emotions resulting in reduced awareness of surroundings or inner sensations. This reduced awareness is a way to cope with emotional triggers in the environment or from memories that would otherwise reawaken a sense of immediate danger.
· Beliefs about oneself as diminished, damaged, or worthless, accompanied by feelings of shame, guilt, or failure related to the traumas that are relatively stable.
Self-perception, shame, and embarrassment of feeling different from others and not incorporating themselves into “normal life.” Resulting in the sense of helplessness or guilt for struggling to survive their traumas. To even include viewing themselves as shameful and deserving of the traumas.
Those with CPTSD have a stronger sense of self and identity even though they may struggle with feelings of low self-worth and believing that they are damaged or broken.
· Interpersonal problems resulting in difficulties in sustaining relationships or feeling close to others.
It is more internal and revolves around feelings of low self-worth. And feeling like they are broken or unlovable.
This sense of low self-worth is most likely developed or impacted by prolonged, repeated, or repetitive trauma(s) experienced.
Self-worth is the narrative or story that we have about ourselves. And if the narrative that you have developed about yourself consists of statements like ‘I’m broken, ‘I’m worthless,’ or ‘I’m unlovable,’ it was most likely created or developed during the ongoing trauma(s) that were experienced.
This can also be seen as mistrust in others and, as a result, keeps others at a distance out of fear of being hurt again. This results in fear of relationships because they do not feel safe. This is especially true for those who experience interpersonal traumas, especially those supposed to keep them safe. Because they were shown repeatedly by their perpetrator that trusting others was not always safe, this can result in a person with CPTSD choosing to isolate from relationships.
And right away, there is an overlap between CPTSD and BPD because of the behavioral and personality changes seen in CPTSD that mimic BPD.
Distorted sense of the perpetrator or preoccupation with revenge
A distorted sense of the perpetrator is most commonly seen when the victim was a child when the trauma occurred. And is seen most commonly when the perpetrator is a family member and may be conveyed with statements such as:
· “They’re family and didn’t mean it.”
· “It wasn’t their fault.”
· “They didn’t know what they were doing.”
And can even include the victim of childhood trauma trying to cover up or minimize what was done to them and its impact. It can be challenging for a child or even an adult of childhood trauma to reconcile that the person they loved was the one that hurt them. And how they feel about them can be very difficult. And can sometimes result in splitting and is a defense mechanism that splits that person into the ‘good safe’ version of that person and the ‘bad not safe’ version of that person. That allowed childhood trauma victims to survive their environment by experiencing their perpetrator as two distinct individuals.
There can also be a preoccupation with revenge against the perpetrator(s) that harmed you, wanting to hurt them like they hurt you, or even wanting to kill them for what has been done.
When the trauma is kept secret, as is frequently the case in child abuse, neglect, sexual, and domestic violence, the survivor’s symptoms are baffling and can be misdiagnosed as BPD.
Common co-occurring disorders
This information is specific to PTSD because CPTSD is not yet recognized in the DSM-5. However, However, I imagine that those with CPTSD are also at risk of experiencing similar co-occurring disorders as PTSD. And those with PTSD are 80% more likely to have a co-occurring disorder than those without PTSD. Some of these co-occurring disorders are substance use, depressive, bipolar, and anxiety disorders.
How is BPD and CPTSD Similar
BPD and CPTSD get confused with one another because there is an overlap between the core symptoms that most mental health professionals only recognize as BPD.
In both of these diagnoses, there are issues seen with:
- Emotional regulation
- Anger
- Avoidance
- Intense expression of emotions that can be frightening
- Substance use to manage emotions
- Emotional triggers
- Concept of self
- Chronic feelings of emptiness
- Interpersonal struggles.
- Struggle to develop and maintain healthy interpersonal relationships
- Increased risk of suicide
- Thoughts
- Dissociation
- Going “away” for a bit in order to cope with triggers
- Self-harming
- BPD – 48.7% report self-harm
- CPTSD – 14.3% report self-harm
While BPD does not require a history of trauma to develop BPD, research indicates that trauma with this population frequently occurs. For example, in a sample of adults in psychiatric treatment diagnosed with BPD, 81% reported histories of interpersonal trauma in childhood, including physical abuse (71%), sexual abuse (68%), and witnessing domestic violence (62%). This is one of many psychiatric diagnoses for which childhood trauma exposure has been demonstrated to be a risk factor. The same is true for CPTSD is those with the heaviest childhood trauma also have an increased risk of severe impairment in multiple areas of their life.
And again, there is a significant overlap between BPD and CPTSD. Not just between the 3 overlapping diagnostic criteria. But with literature demonstrating that those with BPD are not the only diagnostic criteria that engage in self-harm. And while those with CPTSD engage in self-harm less frequently, this is not an effective way to distinguish between BPD and CPTSD. And then, there is also the literature showing that those with BPD can also have a trauma history that would be characteristic of those with CPTSD.
How are BPD and CPTSD different:
- Emotional Regulation
- BPD –
- Real or perceived fears of abandonment
- Fear of being alone
- Seeks relationships and may go in and out of relationships to manage fears of abandonment or loneliness.
- Real or perceived fears of rejection
- CPTSD –
- Doesn’t fear abandonment
- More likely to avoid relationships out of fear of trusting or vulnerability
- May leave relationships when they get attached due to vulnerability
- Shame based fear
- BPD –
- Concept of self
- BPD –
- Sense of self is less concrete and can fluctuate drastically in a short period of time from highly positive to highly negative.
- May change parts of their identity depending on social groups (i.e., hair, fashion, beliefs, sexuality, name, etc.…).
- Unstable sense of self and not knowing who they are.
- CPTSD –
- Stronger sense of self and more concrete.
- Stable sense of self and may view themselves as damaged or broken or worthless but know who they are.
- Negative sense of self that is relatively stable.
- BPD –
- Interpersonal Relationships
- BPD –
- Constantly on alert for real or perceived abandonment “are you going to leave me?”
- More critical of others – may wound or be vindictive of others over a perceived slight.
- “I can’t live if they leave me.”
- CPTSD –
- Constantly on alert for security and safety “am I safe with you?”
- More critical of self – I’ve been shown that I’m shameful or bad.
- “It would suck if they leave me, but ultimately I would be okay.”
- BPD –
- Suicide
- BPD –
- Thoughts, feelings, and attempts are more along the theme of rejection “no one loves me,” or “I don’t want to be alone.”
- CPTSD –
- Thoughts, feelings, and attempts are more along the theme of “I can’t live like this anymore, and it’ll never get any better.”
- BPD –
- Self-harming
- BPD –
- More likely to self-harm to draw others back into the relationship “I’ll hurt myself if you leave me.”
- CPTSD –
- More likely to self-harm in ways that don’t draw attention and are not used to draw people back into the relationship.
- BPD –
Given the significant overlap between BPD and CPTSD, it can be difficult for even the most seasoned mental health professional to distinguish between the two. But here are ways that BPD and CPTSD are different:
Coping with Self-Harming Behaviors:
1. Thinking things through when you want to self-harm. And developing an awareness of what you are thinking and the impulse to want to self-harm. As well as why you want to self-harm and what the behaviors are doing for you. Are they helping you distract from emotional pain, or are they helping you express your emotional pain?
Other alternatives: There are TIP skills (Marsha Linehan DBT) that can be used to help intense emotions if you need to distract. There are other ways to express your emotional pain, such as journaling, drawing, or talking yourself or with someone else through your emotional pain.
2. Putting self-harm off for a while. Make a concentrated effort to delay in self-harming and spend that time trying something different. You may discover that when you put it off that you can tolerate the emotions. Emotions are fairly short-lived and will begin to wane after 15-20 minutes. By doing this, you also begin to develop impulse control and may discover that you are stronger or more resilient than perhaps you realize.
3. Do something else instead. Make a list of other non-self-harming activities that you can do. For example, if self-harming makes you feel calmer or better, perhaps a good alternative would be exercise. Both self-harming and exercise promote the release of endorphins into the body that make us feel better. There are also the options of putting on a favorite show or movie and focusing on it instead.
Treatment Modalities
Treating BPD and CPTSD uses very different treatment modalities, so getting the correct diagnosis is so important.
There are several treatments that are most often used to manage BPD.
Dialectical Behavior Therapy (DBT) focuses on the concept of mindfulness and being in the present. DBT also teaches skills to control intense emotions, reduce self-destructive behavior, manage distress, and interpersonal relationship skills. It seeks a balance between acceptance and change. So that two things that are opposite can be both be true. And was created by Marsha Linehan to treat those with BPD specifically [affiliate link]. DBT can be done in individual therapy sessions and group therapy sessions. Presently, DBT has been the most researched and studied form of treatment for BPD and presently also the most effective.
Mentalization-Based Therapy (MBT) is a form of talk therapy that helps people identify and understand what others might be thinking and feeling. And can be used to help build skills in emotion regulation with those that experience strong emotional responses around interpersonal relationships.
Medications cannot cure BPD but can help with co-occurring disorders often seen with those with BPD. Such as anxiety, depression, impulsivity, etc.…
Self-Care activities include regular exercise, good sleep, a healthy diet, stress management, and taking medications as prescribed. It can help reduce common symptoms of BPD, such as mood fluctuations, impulsive behavior, and irritability, and create new healthier coping skills that those with BPD can truly benefit from.
There are several treatments that are most often used to manage CPTSD.
Cognitive Behavioral Therapy (CBT) is highly effective in treating those with CPTSD. The focus of this therapy is to change unhelpful thinking and behaviors. This form of therapy can also change a person’s narrative from a place of shame to a place of healing. In addition, CBT reduces emotional distress, mental distress, and self-defeating behaviors that can keep a person feeling trapped.
Eye Movement Desensitization and Reprocessing (EMDR) is a fairly new therapy that has been shown to help those who have experienced trauma can recover. This form of therapy is a specialization and requires a licensed mental health professional who has completed the training to do it. And has been shown in numerous studies to help trauma survivors heal faster than through just traditional therapy alone. In addition, EMDR successfully alleviates symptom severity in as few as 3-12 treatment sessions.
