What Is Complex Posttraumatic Stress Disorder and How Does It Relate to Borderline Personality Disorder?

SPECIAL REPORT: ANXIETY & STRESS DISORDERS

Although not outlined in the DSM-5-TR, complex posttraumatic stress disorder (cPTSD) has been identified as a separate diagnosis from PTSD in the ICD-11. The ICD-11 defines cPTSD as the presence of symptoms synonymous with PTSD (including hyperarousal, avoidance, and reexperiencing), as well as emotional dysregulation, negative self-concept, and interpersonal difficulties.¹ It is believed to occur after exposure to severe and repeated trauma typically during early life stages. In many patients, these diagnostic criteria seem to overlap with borderline personality disorder (BPD; Figure). According to DSM-5-TR, those diagnosed with BPD experience a pervasive pattern of instability in interpersonal relationships, an unstable sense of self, and impulsivity and emotional lability.² These patients often struggle with an intense fear of abandonment. Although exposure to trauma is not a prerequisite for a diagnosis of BPD, studies show that anywhere between 30% and 90% of those with BPD meet criteria for a trauma-based disorder or report a history of trauma.^3,4

Perhaps the delineation between cPTSD and BPD lies in the image of oneself and how it interplays in their relationships. With cPTSD, the negative sense of self may manifest as avoidance and disconnection, whereas with BPD, the unstable sense of self may result in a relationship that is volatile and intense. There have been arguments about the validity of cPTSD as either an individual diagnosis or rather a subset of PTSD comorbid with BPD. Often, chronic PTSD can lead to personality modifications that are clinically similar to BPD.

However it is defined, there may be commonalities in how these patients react to stress despite the origins of their anxiety. In turn, treatment approaches between these diagnoses may present similar challenges. It is not uncommon for patients with either diagnosis to be resistant to multiple medication trials, highlighting the importance of a multidisciplinary treatment approach and incorporation of different therapy modalities. Outlined in 2 separate patient cases—one with a diagnosis of cPTSD and another with a diagnosis of BPD—there are clear overlaps in terms of treatment management.

Patient Case With cPTSD

“Mr Shawn” is a 46-year-old man with a diagnosis of cPTSD (previously misdiagnosed as bipolar II disorder), generalized anxiety disorder (GAD), panic disorder, depression, and methamphetamine use disorder in remission. He experienced significant trauma during childhood, in the military, and into adulthood, all of which have caused frequent flashbacks and nightmares. He was sexually abused by his stepmother as a teenager and later struggled with an emotionally abusive marriage and subsequent custody battle after the divorce. He suffered from insomnia, likely because of PTSD nightmares and anxiety, which initially led to a misdiagnosis of bipolar II disorder. His anxiety seemed to originate from his tendency to catastrophize stressors (primarily related to recurrent hemiplegic migraines) or from exacerbation of PTSD. It would present as severe panic attacks with difficulty stopping recurrent images of trauma and with reliving previously traumatic experiences. He had good insight and could manage baseline anxiety using coping skills such as deep breathing exercises, distraction, and mentalization; however, he had difficulty managing severe panic attacks characterized by intense anger and volatility. This resulted in isolation and limited socialization in an attempt to avoid triggers, as well as constant self-deprecation due to his inability to control mood lability.

He was prescribed different antipsychotics (lurasidone, olanzapine, risperidone, quetiapine) and other mood stabilizers (lamotrigine, lithium, valproic acid, carbamazepine) to target mood lability, as well as selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs), prazosin, and cyproheptadine primarily for PTSD symptoms. He was also prescribed as-needed medications for anxiety, including clonidine, gabapentin, hydroxyzine, and clonazepam. He was particularly sensitive to medication changes, so most—if not all—medication trials resulted in worsening symptoms or severe adverse effects.

Even before trying different medications, he had been open to alternative treatment approaches, including lifestyle modifications and psychotherapy. He participated in weekly (now monthly) psychotherapy with a therapist who was also a veteran. His therapist has used multiple therapy approaches, including cognitive processing therapy, cognitive behavior therapy, exposure therapy and somatic experiencing, and dialectical behavior therapy. Although medications seem to provide limited benefit for his PTSD and anxiety, his participation in therapy has allowed him to build the confidence to become more involved with his church community and find his identity through his faith. Through church, he was able to meet his current wife, and he has found emotional outlets such as playing guitar for his church music group. Additionally, he was prescribed low-dose prochlorperazine for his migraines by his neurologist, which has also been helpful as needed for panic attacks.

Patient Case With BPD

“Ms Carter” is a 43-year-old woman with a psychiatric history significant for BPD, attention-deficit/hyperactivity disorder (ADHD) combined inattentive and hyperactive type, and GAD. She was first diagnosed with BPD while in the military through psychological testing (Million Clinical Multiaxial Inventory-IV and Minnesota Multiphasic Personality Inventory). She also experienced trauma in early childhood after being repeatedly molested by her uncle, and severe stress in early adulthood after her father died tragically in a house fire. Much of her recent anxiety stems from financial stressors (ie, an inability to maintain a stable job and pay bills each month), difficulties transitioning from military life to civilian life, and tumultuous relationships with her parents and current husband.

She struggled with finding her sense of identity and role in society after leaving the military, which contributed greatly to her anxiety. She tended to self-isolate due to fear of abandonment because she had multiple turbulent previous marriages that ended in divorce and an on-and-off relationship with her father, but she was closely reliant on her husband as he was one of her only consistent relationships. Her anxiety tended to manifest itself as tension and mood fluctuations between intense irritability, tearfulness, and hostility usually targeted toward her husband. Her anxiety was also frequently accompanied with physical symptoms (racing heart, sweaty palms, abdominal discomfort, and worsening chronic pain). She would often wake up throughout the night feeling a sense of unease and would have difficulty falling back asleep due to her inability to quiet her mind. Though it has been historically difficult to determine whether her anxiety is linked to GAD vs untreated ADHD, it is likely that there is overlap in symptomatology.

Initially, she was resistant to more intensive psychotherapy, which she attributed to fear of “starting over” with a new provider and worries about the patient-therapist alliance. She primarily wanted to manage her symptoms with medications and had unsuccessful trials of multiple SSRIs/SNRIs with and without augmentation with mood stabilizers (notably, lamotrigine and valproic acid) and aripiprazole. She also tried different stimulants for her ADHD, which seemed to only exacerbate her anxiety further. Ultimately, after several years working with her psychiatrist and seeing limited benefits with medication trials, she agreed to initiating individual psychotherapy in conjunction with medications. She began with biweekly dialectical behavior therapy, then transitioned to eye movement desensitization and reprocessing therapy (in view of her history significant for childhood sexual trauma). She also participated in cognitive behavior therapy for insomnia and improved her sleep hygiene. In addition, she was tried on low-dose quetiapine for mood/anxiety and atomoxetine for ADHD. She began to see small but meaningful improvements with this regimen.

Treatment Considerations

Though Mr Shawn and Ms Carter carry different diagnoses with precipitation of their anxiety by different current stressors, there are similarities in terms of their responses to treatment and their history of experienced trauma. Both patients were resistant to multiple medication trials but began to see benefits with the addition of therapeutic modalities outside the scope of pharmacotherapy. As a psychiatrist, it may be easy to fall into the idea that pharmacotherapy is necessary in the treatment of mood symptoms. Although medications play an important part in the treatment, they should not be considered the only option. It is not unreasonable to initiate medications such as SSRIs/SNRIs or other antidepressants with or without augmentation with antipsychotics to target symptoms of anxiety and depression commonly comorbid with PTSD and BPD; however, these historically have modest benefits. Mood stabilizers can also play a role in mood lability and impulsivity seen with cPTSD and BPD, though treatment with psychotherapy should ultimately be considered first line.^5,6

Therapeutic approaches that would likely be most beneficial for either diagnosis would be those targeting emotional dysregulation and processing trauma. The idea that trauma can precipitate emotional dysregulation and poor self-identity can help address symptoms in patients with cPTSD and BPD. As mentioned earlier, although trauma is not a prerequisite for BPD, it is commonly seen in this patient population (as seen in Ms Carter’s case). Dialectical behavior therapy—currently the most empirically supported treatment for BPD—has been shown to be efficacious for patients with cPTSD in regard to addressing emotional lability and regulation.⁷ Additionally, therapies focusing on trauma processing, such as cognitive processing therapy,^8,9 eye movement desensitization and reprocessing,¹⁰ and prolonged exposure therapy,¹¹ may be helpful for patients with cPTSD and BPD. Consideration of other psychotherapy types, including acceptance and commitment therapy with a focus on mindfulness and cognitive behavioral changes, can help those with cPTSD and those with BPD in better managing anxiety and improving socialization.^12,13

Outside of psychotherapy, it is important to consider lifestyle modifications that address psychosocial stressors and other medical diagnoses. Discovering emotional outlets to help relieve stress rather than internalizing anxiety (ie, music in Mr Shawn’s case) and focusing on improving sleep hygiene (ie, Ms Carter’s case) can have lasting effects on mental health in patients with cPTSD and BPD. Additionally, understanding how other medical diagnoses may exacerbate anxiety symptoms (Mr Shawn with hemiplegic migraines and Ms Carter with ADHD and chronic pain) and treating them appropriately is vital for patient care.

Concluding Thoughts

Ultimately, whether a patient has a diagnosis of cPTSD, BPD, or some combination of both, treatment should be considered multifaceted and overlapping. Medications can provide some benefits in these patient populations, but looking at a holistic picture and addressing symptoms with different psychotherapy types and behavioral modifications can be more impactful.

Dr Gutierrez is the chief resident physician, PGY-3, in the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center. Dr Tucker is professor emeritus and volunteer faculty in the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center.

References

1. Complex post traumatic stress disorder. International Classification of Diseases, 11th Revision. Accessed May 26, 2024. https://icd.who.int/browse/2024-01/mms/en#585833559

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2022.

3. Bozzatello P, Rocca P, Baldassarri L, et al. The role of trauma in early onset borderline personality disorder: a biopsychosocial perspective. Front Psychiatry. 2021;12:721361.

4. Leichsenring F, Fonagy P, Heim N, et al. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry. 2024;23(1):4-25.

5. Ripoll LH. Psychopharmacologic treatment of borderline personality disorder. Dialogues Clin Neurosci. 2013;15(2):213-224.

6. Holtzheimer P, Montaño M. Clinician’s guide to medications for PTSD. US Department of Veterans Affairs. Accessed May 26, 2024. https://www.ptsd.va.gov/professional/treat/txessentials/clinician_guide_meds.asp

7. Bohus M, Kleindienst N, Hahn C, et al. Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse: a randomized clinical trial. JAMA Psychiatry. 2020;77(12):1235-1245.

8. Courtois CA. Complex trauma, complex reactions: assessment and treatment. Psychother Theory Res Pract Train. 2004;41(4):412-425.

9. Kleindienst N, Steil R, Priebe K, et al. Treating adults with a dual diagnosis of borderline personality disorder and posttraumatic stress disorder related to childhood abuse: results from a randomized clinical trial. J Consult Clin Psychol. 2021;89(11):925-936.

10. Mosquera D, Leeds AM, Gonzalez A. Application of EMDR therapy for borderline personality disorder. J EMDR Pract Res. 2014;8(2):74-89.

11. De Jongh A, Groenland GN, Sanches S, et al. The impact of brief intensive trauma-focused treatment for PTSD on symptoms of borderline personality disorder. Eur J Psychotraumatol. 2020;11(1):1721142.

12. Reyes-Ortega MA, Miranda EM, Fresán A, et al. Clinical efficacy of a combined acceptance and commitment therapy, dialectical behavioural therapy, and functional analytic psychotherapy intervention in patients with borderline personality disorder. Psychol Psychother. 2020;93(3):474-489.

13. You S, Son C. Effects of acceptance and commitment therapy (ACT) on complex PTSD symptoms, acceptance, and post-traumatic growth of college students with childhood emotional abuse. J Digit Converg. 2018;16:561-572.