Borderline Personality Disorder and Complex Posttraumatic Stress Disorder: Myths in Diagnosis

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COMMENTARY

The history of psychiatry is marked by popular trends and shifts in theory and diagnosis. One such current trend is the diagnosis of complex posttraumatic stress disorder (CPTSD), which was added to the ICD-11 in June 2018. The disorder is not recognized by the American Psychiatric Association and is not listed in DSM-5-TR, which only recognizes severe posttraumatic stress disorder (PTSD).

The addition of CPTSD as a diagnostic entity in ICD-11 has been controversial, in part because of attempts to reconceptualize some patients with borderline personality disorder (BPD) as having CPTSD. A recent literature review concluded that BPD remains a necessary diagnostic entity given the CPTSD construct’s overemphasis on trauma as the main or sole etiological factor in the disorder.¹ There appear to be cases of CPTSD that do not overlap with BPD, but in practice, the CPTSD diagnosis is often being used to avoid the diagnosis of BPD. While many BPD patients do have histories of trauma, emotional neglect has been found to be the most common psychological risk factor.^2,3 Moreover, a diagnosis of CPTSD fails to take into account the role of biological and genetic factors, which play an important role in the development of BPD.⁴

Another conceptual issue in the construct of CPTSD when applied to patients with BPD is that it fails to account for the fundamental dysfunction in personality, which is the locus of this disorder. There are patients with BPD who have been severely and repeatedly traumatized, but they are in the minority.³ BPD is best understood as a final common pathway that emerges from interactions between heritable traits of emotion dysregulation and emotional neglect.²

Given the significant overlap between BPD and CPTSD, it remains unclear whether what is now called CPTSD is anything more than BPD or BPD traits comorbid with PTSD—ie, the presence of both disorders in the same patient—which may not justify giving this presentation a new name.⁵ Research shows that the comorbidity of PTSD with BPD is generally less than 50%, although the presence of this comorbidity tends to be associated with a worse prognosis.⁶

BPD, CPTSD, Stigma, and the Reactions of Clinicians

Patients with BPD are not always popular among clinicians. They can be impulsive and antagonistic, and chronic suicidality is both challenging and disturbing. Many have noted that these patients tend to evoke intense reactions in clinicians, which may come to mirror the emotional state of the patient. As Adler once commented, “the countertransference experience for the therapist often is one of helplessness, rage, despair, and a feeling of personal inadequacy, regardless of how capable the therapist is.”⁷ Omnipotent fantasies can also occur,⁸ in which the clinician may feel that they alone can “save” or “rescue” the patient. As Gabbard has suggested, these reactions can result in boundary violations and abuses of the treatment relationship.⁹

A diagnosis of BPD is associated with a notable stigma.¹⁰ It is possible that changing the diagnosis to CPTSD could be a way of alleviating the clinician’s anxiety around the treatment. Mirroring the patient’s own propensity towards splitting, the clinician may not accept that the patient has both good and bad qualities. Instead, the patient is seen as good and their diagnosis (BPD) bad. To put it another way, when CPTSD is diagnosed, the patient is seen as a passive, helpless victim of past trauma who makes no contributions to their continued suffering. The clinician, in turn, becomes the heroic rescuer, capable of saving the patient from traumatizing others. One can recognize this victim-victimizer dynamic as a hallmark feature of the patient with BPD’s interpersonal relations.

It could be argued that to engage with this type of reaction is to collude with the patient’s defenses. That is, patients may cast the clinician into the role of benevolent helper while simultaneously labeling the others as “all bad,” perpetuating and reinforcing the patient’s propensities towards splitting. Yet, it would be incomplete to consider the clinician’s dilemmas outside of the broader social climate of contemporary mental health. The view that most or all psychiatric illness results from trauma has become an increasingly common refrain, leading McNally to refer to a “culture of trauma.”¹¹

Treatment Implications

We believe that the reconceptualization of BPD as CPTSD has significant consequences on the treatment of these patients, some of them potentially harmful. In addition to the perils of colluding with the patient’s unhealthy defenses, described previously, such reconceptualization also steers vulnerable patients away from effective treatments. There is now an abundance of literature demonstrating that dialectical behavioral therapy (DBT), mentalization-based treatment, and transference-focused psychotherapy have efficacy in the treatment of BPD.¹²

When patients with BPD are misdiagnosed with CPTSD, the treatment recommendation is usually a generic trauma-focused therapy. Since these approaches have no established efficacy in the treatment of BPD—and since a significant number of patients with BPD have no discernible trauma history—such a treatment recommendation may be wholly insufficient in managing the patient’s condition. Given that up to 10% of patients with BPD will eventually die by suicide,¹³ focusing on childhood trauma may not be the best choice. In fact, DBT, the most thoroughly researched method of treatment for BPD, recommends a very different approach—radical acceptance, ie, acknowledging that bad things have happened but it is time to put them behind you and start anew. Empirically-supported psychodynamic therapies also tend to focus largely on the patient’s problems in the here and now of the treatment relationship rather than the problems of the past.

A vital feature of the effective psychotherapy of borderline conditions is the gradual recognition by the patient of their own contributions to the repeating life patterns that perpetuate suffering. The identification and resolution of these cyclical psychodynamics¹⁴ can be said to be the goal of any treatment for BPD, regardless of whether the treatment is skills-based or psychodynamic. When the patient’s problems are identified as resulting from complex trauma, the emphasis of the treatment is on the experience of the traumatic event(s); the patient’s contributions to their pathological patterns of engagement may consequently be downplayed or ignored. Thus, a vital component of treatment, one necessary for the patient’s ultimate recovery, may be erased. Another way of saying this is that effective treatment for BPD must address not only what happened to patients but also, more importantly, what patients now do to themselves in their interactions with the world.

Moreover, trauma-focused therapists tend to avoid the diagnosis of BPD. As such, they lack familiarity with research findings, as well as with fundamental writings by theorists such as Linehan² and Gunderson,¹⁵ or may simply be underprepared for the challenge of treating patients with severe personality psychopathology. The result could well be a failure to provide evidence-based treatment, leading to unnecessary suffering.

Concluding Thoughts

Although CPTSD is a popular modern diagnosis, it must be considered within the broader context of shifting diagnostic trends in the history of psychiatry. Regardless of what we call the syndrome, the core problems of aloneness, abandonment, and identity diffusion, so characteristic of these patients, remain. We believe that the current evidence supports retaining the BPD diagnosis since it describes a distinct psychiatric syndrome that is not wholly captured by the CPTSD construct. Furthermore, it is unclear whether CPTSD adds anything to our current understanding of psychopathology, given that its symptoms are already described by validated diagnoses of BPD and PTSD. The misdiagnosis of BPD as CPTSD carries significant treatment ramifications, some of which may be ineffective or even harmful.

References

1. Paris J. Complex posttraumatic stress disorder and a biopsychosocial model of borderline personality disorder. J Nerv Ment Dis. 2023;211(11):805-810.

2. Linehan MM. Cognitive–Behavioral Treatment of Borderline Personality Disorder. Guilford Press; 1993.

3. Porter C, Palmier-Claus J, Branitsky A, et al. Childhood adversity and borderline personality disorder: a meta-analysis. Acta Psychiatr Scand. 2020;141(1):6-20.

4. Distel MA, Trull TJ, Derom CA, et al. Heritability of borderline personality disorder features is similar across three countries. Psychol Med. 2008;38(9):1219-1229.

5. Atkinson JR, Kristinsdottir KH, Lee T, Freestone MC. Comparing the symptom presentation similarities and differences of complex posttraumatic stress disorder and borderline personality disorder: a systematic review. Personal Disord. 2024;15(4):241-253.

6. Scheiderer EM, Wood PK, Trull TJ. The comorbidity of borderline personality disorder and posttraumatic stress disorder: revisiting the prevalence and associations in a general population sample. Borderline Personal Disord Emot Dysregul. 2015;2:11.

7. Adler G. Uses and limitations of Kohut's self psychology in the treatment of borderline patients. J Am Psychoanal Assoc. 1989;37(3):761-785.

8. Kernberg OF, Selzer MA, Koenigsberg HW, et al. Psychodynamic Psychotherapy of Borderline Patients. Basic Books; 1985

9. Gabbard GO. An overview of countertransference with borderline patients. J Psychother Pract Res. 1993;2(1):7-18.

10. Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harv Rev Psychiatry. 2006;14(5):249-256.

11. McNally RJ. Remembering Trauma. Belknap Press of Harvard University Press; 2003.

12. Leichsenring F, Heim N, Leweke F, et al. Borderline personality disorder: a review. JAMA. 2023;329(8):670-679.

13. Paris J. Suicidality in borderline personality disorder. Medicina (Kaunas). 2019;55(6):223.

14. Wachtel PL. Cyclical psychodynamics and the contextualized mind. Psychother Theor Res Pract Train. 1997;34(3):195-206.

15. Gunderson JG. Borderline Personality Disorder. American Psychiatric Press; 1984.