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Author Topic: DIFFERENCES|COMORBIDITY: Borderline PD and PTSD  (Read 42190 times)
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« on: April 17, 2006, 10:35:14 AM »

Im told that today in physco circles the dx's of PTSD and BPD are virtually interchangeable...can I get some feedback please...thanks

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« Reply #1 on: April 18, 2006, 07:23:42 AM »

Clinicians often use PTSD (which has a reimbursement code) to describe C-PTSD, a disorder first proposed by Judith Herman, MD, a professor of clinical psychology at Harvard University, but one that has yet to be recognized as an official diagnosis. Patients with C-PTSD are often classified as  PTSD, as I mentioned above or  ":)isorder of Extreme Stress, not otherwise specified”, or “personality change due to classifications found elsewhere”. Further complications in diagnosis arise when one considers the high levels of co-morbidity which are seen in patients who have complicated trauma histories.  Diagnosis which often accompany C-PTSD are depression, OCD, Borderline Personality Disorder, Dissociative Disorders such as DID, agoraphobia and social phobia. 

In the context of BPD, some believe that BPD could be divided between suffers that experienced trauma - C-PTSD - and those that did not - BPD. An alternative is to see C-PTSD as a comorbidity with BPD when trauma is a factor.

In her book “Trauma and Recovery”, Herman proposed the diagnosis of Complex Post Traumatic Stress Disorder (C-PTSD) which differs from the definition of PTSD which is a diagnosis best captured by the presence of a single acute trauma (such as a car accident, single rape, or exposure to natural disaster). Although these cases of PTSD are horrific and distressful a different psychological picture emerges when dealing with clients who have been exposed to multiple trauma’s.

The following is a description of the diagnosis as first described by Herman in 1997:

1. A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including those subjected to domestic battering,childhood physical or sexual abuse, and organized sexual exploitation.

2. Alterations in affect regulation, including

    persistent dysphoria
    chronic suicidal preoccupation
    explosive or extremely inhibited anger (may alternate)
    compulsive or extremely inhibited sexuality (may alternate)

3. Alterations in consciousness, including

    amnesia or hypermnesia for traumatic events
    transient dissociative episodes
    reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms or in the form of ruminative preoccupation

4. Alterations in self-perception, including

    sense of helplessness or paralysis of initiative
    shame, guilt, and self-blame
    sense of defilement or stigma
    sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)

5. Alterations in perception of perpetrator, including

    preoccupation with relationship with perpetrator (includes preoccupation with revenge)
    unrealistic attribution of total power to perpetrator (caution: victim’s assessment of power realities may be more realistic than clinician’s)
    idealization or paradoxical gratitude
    sense of special or supernatural relationship
    acceptance of belief system or rationalizations of perpetrator

6. Alterations in relations with others, including

    isolation and withdrawal
    disruption in intimate relationships
    repeated search for rescuer (may alternate with isolation and withdrawal)
    persistent distrust
    repeated failures of self-protection

7. Alterations in systems of meaning

    loss of sustaining faith
    sense of hopelessness and despair

Whether or not C-Ptsd ever appears in the DSM (diagnostic statistical manual of mental disorders) it’s conception has been very important in the field of Trauma.  Obviously, a large number of patients with mental disorders have had complicated histories which often involve catastrophic events which put a strain on the persons coping mechanisms and lead to significant distress.  One could argue that psychological trauma is indicated in too many disorders and therefore is not specified enough to merit it’s own categorization. 

The presence of C-PTSD can be quite validating for patients who have suffered silently from such atrocities throughout their lifetime. In her book “Trauma and Recovery” Herman writes:

    Many abused children cling to the hope that growing up will bring escape and freedom.

    But the personality formed in the environment of coercive control is not well adapted to adult life. The survivor is left with fundamental problems in basic trust, autonomy, and initiative. She approaches the task of early adulthood――establishing independence and intimacy――burdened by major impairments in self-care, in cognition and in memory, in identity, and in the capacity to form stable relationships.”

    She is still a prisoner of her childhood; attempting to create a new life, she reencounters the trauma.
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« Reply #2 on: April 21, 2006, 06:23:12 AM »

I've added this to several of the discussions on comorbidity...

When asking differential questions about multiple personality disorders, it is important to understand why you are asking the question and how you intend to use the information. Without this perspective and focus, the data may be overwhelming, confusing and misleading.  For example:

~ if your child is not responding to therapy, it makes sense to look more carefully into the possibility that the wrong illness was diagnosed or whether there are comorbid (multiple) personality disorders at play. Bipolar and Major Depressive Disorder, for example, are far more responsive to pharmaceutical therapy than Borderline Personality.

~ If you are trying to get along better with your wife, it's not as important to precisely pinpoint the specific disorder or analyze the comorbidity as it is to recognize and fully understand the problem behaviors and how to constructively deal with them.  

~ If you are recovering from a failed relationship, the important thing is often to understand which behaviors were pathologic (mental illness) and which were just the normal run of the mill problems common to failing/failed relationships - there is often a bias to assign too much to the "pathology" and not enough to common relationship problems, or the issues we created by our own behaviors.

It's important to know that the distinctions are not all that neat and tidy. In an NIH study, comorbidity with another personality disorder was very high at 74% (77% for men, 72% for women).  This is one reason why there is controversy around the DSM classifications of Personality Disorders - there is so much overlap it is confusing even to professionals - personality disorders are real, but they are not easily or neatly defined.
More info

In the study, comorbidity with mood disorders was also very high at 75% as was anxiety disorders 74%.
Mood/Anxiety Comorbidities ----
Anxiety Disorder
-Post traumatic stress
-Panic with agoraphobia
-Panic w/o agoraphobia
-Social phobia
-Specific phobia
-General anxiety
Mood Disorder
-Major depressive
-Bipolar I
-Bipolar II
More info

Some helpful hints for sorting through this.

  • General and Specific There are definitions for "personality disorder" as a category and then there are definitions for the subcategories (i.e., borderline, narcissistic, antisocial, etc.).  Start with the broader definition first.  Keep in mind that to be a personality disorder, symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder - - the history of symptoms can be traced back to adolescence or at least early adulthood - - the symptoms have caused and continue to cause significant distress or negative consequences in different aspects of the person's life. Symptoms are seen in at least two of the following areas: thoughts (ways of looking at the world, thinking about self or others, and interacting), emotions (appropriateness, intensity, and range of emotional functioning), interpersonal functioning (relationships and interpersonal skills), or impulse control

  • Spectrum Disorders  An extremely important aspect of understanding mental disorders is understanding that there is a spectrum of severity. A spectrum is comprised of relatively "severe" mental disorders as well as relatively "mild and nonclinical deficits".  Some people with BPD traits cannot work, are hospitalized or incarcerated, and even kill themselves.  On the other hand, some fall below the threshold for clinical diagnosis and are simply very immature and self centered and difficult in intimate relationships.

  • Comorbidity Borderline patients often present for evaluation or treatment with one or more comorbid axis I disorders (e.g.,depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa). It is not unusual for symptoms of these other disorders to mask the underlying borderline psychopathology, impeding accurate diagnosis and making treatment planning difficult. In some cases, it isn’t until treatment for other disorders fails that BPD is diagnosed.  Complicating this, additional axis I disorders may also develop over time.  Because of the frequency with which these clinically difficult situations occur, a substantial amount of research concerning the axis I comorbidity of borderline personality disorder has been conducted. A lot is based on small sample sizes so the numbers vary.  Be careful to look at the sample in any study -- comorbidity rates can differ significantly depending on whether the study population is treatment seeking individuals or random individuals in the community.  Also be aware that comorbidity rates  are generally lower in less severe cases of borderline personality disorder.

  • Multi-axial Diagnosis  In the DSM-IV-TR system, technically, an individual should be diagnosed on all five different domains, or "axes." The clinician looks across a large number of afflictions and tries to find the best fit.  Using a single axis approach, which we often do as laymen, can be misleading -- looking at 1 or 2 metal illness and saying "that's it" -- if you look at 20 of these things, you may find yourself saying "thats it" a lot.   Smiling (click to insert in post)  A note in the DSM-IV-TR states that appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”.

  • Don't become an Amateur Psychologist or Neurosurgeon  While awareness is a very good thing, if one suspects a mental disorder in the family it is best to see a mental health professional for an informed opinion and for some direction - even more so if you are emotionally distressed yourself and not at the top of your game.  
I hope this helps keep it in perspective.   Smiling (click to insert in post)


DIFFERENCES|COMORBIDITY: Overview of Comorbidity
Additional discussions...
Personality Disorders
Borderline and Paranoid Personality Disorder
Borderline and Schzoid/Schizotypal Personality Disorder
Borderline and Antisocial Personality Disorder
Borderline and Histrionic Personality Disorder
Borderline and Narcissistic Personality Disorder
Borderline and Avoidant Personality Disorder
Borderline and Dependent Personality Disorder
Borderline and Obsessive Compulsive Personality Disorder
Borderline and Depressive Personality Disorder
Borderline and Passive Aggressive Personality Disorder
Borderline and Sadistic Personality Disorder
Borderline and Self Defeating Personality Disorder
Borderline PD and Alcohol Dependence
Borderline PD and Aspergers
Borderline PD and Attention Deficit Hyperactivity Disorder
Borderline PD and BiPolar Disorder
Borderline PD and Dissociative Identity Disorder
Borderline PD and P.T.S.D.
Borderline PD and Reactive Attachment Disorder (RAD)
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« Reply #3 on: April 21, 2006, 03:52:46 PM »

Sometimes 'Complex PTSD' or DESNOS (disorder of extreme stress not otherwise specified) is considered to be the same as BPD. The term complex ptsd was originally coined by Dr. Judith Herman to describe the effects of long term abuse and exploitation. It's different from regular ptsd which occurs as the result of a single, isolated event. The following is from: www.ncptsd.va.gov/facts/specific/fs_complex_ptsd.html

What are the symptoms of Complex PTSD?

The first requirement for the diagnosis is that the individual experienced a prolonged period (months to years) of total control by another. The other criteria are symptoms that tend to result from chronic victimization. Those symptoms include:

* Alterations in emotional regulation, which may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger

* Alterations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body

* Alterations in self-perception, which may include a sense of helplessness, shame, guilt, stigma, and a sense of being completely different than other human beings

* Alterations in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge

* Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer

* Alterations in one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair

My personal opinion is that a person can experience ptsd symptoms (emotional numbing, hyper arousal, dissociation, etc.) from prolonged exposure to an abusive environment, and not necessarily meet the criteria for BPD. It would be pretty amazing for someone to live through years of chronic abuse and emerge completely unscathed. However, this doesn't mean they will resort to using primitive defense mechanisms (splitting, etc.), or the interpersonal push/pull as seen in BPD.

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« Reply #4 on: April 21, 2006, 06:24:25 PM »

Just an aside... I think there are some doctors/researchers who subscribe to the notion that BPD might possibly be considered PTSD of a most severe and chronic degree. This would be based upon the supposition that the BPD-sufferer experienced some form of early childhood trauma or ongoing neglect or abuse. (Joseph Santoro, author of The Angry Heart?)

I can see how this correlates, especially in someone with a predisposition, but I do not believe it to be universal for *all* BPD-sufferers.

And certainly all who suffer from PTSD (or Syndrome) would not be considered to have BPD.

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« Reply #5 on: May 08, 2006, 06:13:59 AM »

Complex PTSD is not yet officially recognized and is being proposed for addition to the DSM-V by Judith Herman.

Mod Note: It was not added to the 2013 DSM 5
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« Reply #6 on: May 08, 2006, 06:32:09 PM »

I've thought about this a lot.

My layman's understanding is that PTSD and complex PTSD have clearly established external causes. Simple PTSD = single incident trauma (assault, accident); Complex PTSD = repetitive trauma (abuse, combat stress). Some people who experience trauma do not have PTSD (e.g., only half of rape victims get it), but everyone who has PTSD has experienced trauma.

We're not really sure what causes BPD. We think that in general, it's a combination of early childhood trauma combined with a genetic predisposition towards high emotionality. However, some people appear to have BPD without any serious traumatic causes (see the section on this board for parents of BPD children).

I had some BPD-like behavior following a stalking incident in college - cried easily, hypervigilant, hypersensitive, overreacting to others - but in retrospect, this was PTSD.

So it's perfectly possible for both to co-exist, but they're also separate. The specifics are fuzzy. How's that for a brilliant non-answer? :Smiling (click to insert in post)
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« Reply #7 on: May 12, 2006, 11:49:42 PM »

I recommend this article written by experts in the field of complex trauma. As I understand it, the term DESNOS (disorders of extreme stress not otherwise specified) is interchangeable with complex ptsd.

The following is from: www.traumacenter.org/products/pdf_files/DESNOS.pdf

Characteristic of DESNOS is trauma which involves interpersonal victimization, multiple traumatic events, or events of prolonged duration. Disturbances in six areas of functioning are required for the diagnosis: (1) regulation of affect and impulses; (2) attention or consciousness; (3) self-perception; (4) relations with others; (5) somatization; and (6) systems of meaning. The authors offer clinical examples of each of these and go on to describe psychometric tests that can be used as valuable diagnostic aides.


Empirical research has established that the BPD and DESNOS diagnoses in general represent overlapping but distinct symptom profiles. On the surface, these disorders may appear to be quite similar, as both relate to aspects of four of the six domains of self-regulatory deficit captured by the DESNOS construct (i.e., affect, attention/consciousness, self-perception, and relationships). Several important distinctions exist, however, between DESNOS and the classic BPD construct, including notable differences in the relative importance and nature of disruptions in these four domains of self-regulation. For instance, whereas chronic affect dysregulation is the hallmark feature of DESNOS, this symptom is secondary to disturbances in identity and relationships with others in BPD. In essence, BPD represents a disorder of attachment, while DESNOS is considered by most leading clinicians and researchers in the field to be better understood as a disorder of self-regulation.

Affect Regulation

Affect in DESNOS patients is more chronically and persistently emphasized in the direction of a downward dysregulation than is the case in BPD patients, who in contrast exhibit greater range in their capacity for transient upward emotional spikes. The continuum of mood in patients with DESNOS typically ranges from a dysthymic/anxious baseline to profound states of rage, terror, or hopelessness. The brief periods of excitement, positive anticipation, and euphoria observed in BPD patient—often associated with transient idealizations of new intimate others or treatment providers—are less commonly observed to be components of a true DESNOS symptom presentation. In fact, a cardinal but under-recognized feature of DESNOS patients is their profound deficit in the capacity to sustain positive emotional states, experience pleasure, and become absorbed in positive and present-focused states of awareness.


The nature of interpersonal dysfunction characterized by the DESNOS construct varies from that of the BPD diagnosis as articulated in the DSM-IV. The BPD patients fundamental interpersonal orientation is an active one: an approach-based stance characterized by the duality of desire and disillusionment. BPD is often characterized by the oscillation between intense longing and search for idealized (and therefore unrealistic and ultimately untenable) relationships, and the equally intense devaluation and ultimate sabotage of these relationships. Conversely, when an intimate other threatens to pull out of what had been perceived by the patient to be an unsatisfying relationship, the BDP patient can become overcome with a resurgence of desire to maintain this relationship occasioned by desperate fear of abandonment and rejection by the other. In other instances, the BPD patient will concoct, and become temporarily consumed by vaguely articulated fantasies of a “perfect” future with a new caregiver or potential lover, only later to feel the sting of disappointment at the others inability to fill the profound emptiness at the core of his or her own being. As has been well established and the subject of much of the clinical literature on BPD, these patterns typically manifest themselves early in these patients transference responses to new treatment providers.

In contrast, the basic interpersonal orientation of the DESNOS patient is passive in nature, characterized by a duality of avoidance and revictimization. For example, these patients often engage in prolonged periods of self-inflicted social isolation and avoidance of intimate contact. At other times, however, they report abruptly discovering themselves to be in the midst of an intense emotional relationship that feels unsafe or out of control. In fact, when DESNOS patients do enter intimate relationships, it is often as a result of being the target of victimizing others who have been drawn to these patients emotional vulnerability, underdeveloped capacity to identify danger cues, and tolerance for violence and boundary violations as an inherent component of intimate relationships. DESNOS patients are often observed, to the chagrin of their therapists, to reenact their interpersonal traumas, repeatedly finding themselves helplessly playing out the role of victim, or, alternately, compelled to victimize others in ways similar to those experienced in their own history of childhood traumatization.

DESNOS patients not only tend to fear and believe themselves to be unworthy of meaningful relationships with others; they are generally incapable of imagining a future for themselves in which they can love and be loved in a relationship that is free of abuse. Given this pessimism about the potential for positive interpersonal connection and general distrust of others, DESNOS patients are not surprisingly somewhat less likely than patients with BPD to engage in boundary violations and intrusiveness with their therapists at the outset of treatment. In contrast, they often present as apprehensive, guarded, and at times hostile toward new treatment providers. The establishment of safety and trust is perhaps the most important component of the initial phase of treatment with these patients.


Dissociative symptom presentations differ notably in patients with these two disorders. Dissociative symptoms associated with BPD are characterized by transient responses to stress, the occurrence of which is not required to meet diagnostic criteria. Clinical research on dissociative symptomatology as measured by the DES has consistently found that patients with BPD report lower levels of dissociative symptoms than patients with PTSD. 88 In contrast, the presence of significant dissociative symptomatology is an essential and required component of the DESNOS diagnosis. These symptoms may take a variety of forms ranging from episodic experiences of derealization to lasting psychogenic amnesia for portions of ones traumatic experiences, to the presence of Dissociative Identity Disorder.


The following distinctions can be made regarding the type and extent of disturbances in self-perception observed in these two disorders. Whereas the primary feature of disturbance in self-perception for patients with BPD involves a fundamental confusion about self, the DESNOS patient experiences a self that has been permanently damaged and alienated from others. At the core of identity disturbance for patients with classic BPD lays the absence of a sense of self or ego identity, and the persistent affective experience of emptiness associated with the void left by the unformed self. Perhaps the key component of the severe psychopathology of these patients is the intolerable black hole of this void that always beckons, making the risk for suicide a constant consideration in treatment. DESNOS patients, in contrast, although plagued by negative affect states of guilt, shame, and ineffectiveness associated with their experience of a damaged self, nevertheless possess, on some fundamental level, a basic core sense of identity, albeit often the problematic dual identity of victim and patient. In fact, their desperate clinging to trauma-based identities as victim/patient is often quite pronounced, as it becomes a source of personal meaning-making and provides a compelling explanatory model for and source of “proof” of their chronic experience of interpersonal suffering and emotional pain. For such patients, this identity formation is perhaps the greatest obstacle to genuine treatment progress.

« Reply #8 on: May 13, 2006, 08:47:32 PM »

What struck me the most was where the author of the article stated that one of the differences between BPD and PTSD and DESNOS is a sense of self.  BPDs have none where as those with DESNOS have one, but it is permanently damaged given the early onset of prolonged abuse.   While the optimist in me bristles a bit at the author's use of the word "permanent", the statement does ring true.

As for the co-morbidity issue asked about in this thread and as discussed in the articles, I am reminded of something an old T of mine once said:  "I never diagnose someone as having BPD until any trauma issues have been addressed.  If the characteristics are still there after that, then I will consider BPD."   That makes a lot of sense to me especially when I consider that the motivation behind certain behaviors and the thoughts and core beliefs involved are not immediately apparent to the patient or to the therapist.  

Thanks again,

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« Reply #9 on: August 30, 2007, 12:36:31 AM »

Although people with BPD often suffer from PTSD, people with PTSD do not necessarily suffer from BPD.

Types of PTSD:

Normal Stress Response

The normal stress response occurs when healthy adults who have been exposed to a single discrete traumatic event in adulthood experience intense bad memories, emotional numbing, feelings of unreality, being cut off from relationships or bodily tension and distress. Such individuals usually achieve complete recovery within a few weeks. Often a group debriefing experience is helpful. Debriefings begin by describing the traumatic event. They then progress to exploration of survivors’ emotional responses to the event. Next, there is an open discussion of symptoms that have been precipitated by the trauma. Finally, there is education in which survivors’ responses are explained and positive ways of coping are identified.

Acute Stress disorder

Acute stress disorder is characterized by panic reactions, mental confusion, dissociation, severe insomnia, suspiciousness, and being unable to manage even basic self care, work, and relationship activities. Relatively few survivors of single traumas have this more severe reaction, except when the trauma is a lasting catastrophe that exposes them to death, destruction, or loss of home and community. Treatment includes immediate support, removal from the scene of the trauma, use of medication for immediate relief of grief, anxiety, and insomnia, and brief supportive psychotherapy provided in the context of crisis intervention.

Uncomplicated PTSD

Uncomplicated PTSD involves persistent reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, emotional numbing, and symptoms of increased arousal. It may respond to group, psychodynamic, cognitive-behavioral, pharmacological, or combination approaches.

Comorbid PTSD

PTSD comorbid with other psychiatric disorders is actually much more common than uncomplicated PTSD. PTSD is usually associated with at least one other major psychiatric disorder such as depression, alcohol or substance abuse, panic disorder, and other anxiety disorders. The best results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol or substance abuse. The same treatments used for uncomplicated PTSD should be used for these patients, with the addition of carefully managed treatment for the other psychiatric or addiction problems.

Complex PTSD

Complex PTSD Difficulties regulating emotions, including symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger

Variations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes of dissociation (during which one feels detached from one's mental processes or body)

Changes in self-perception, such as a sense of helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings

Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge

Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer

Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair


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