complex ptsd and borderline personality disorder
complex ptsd and borderline personality disorder
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complex ptsd and borderline personality disorder
Clinicians evaluating severely distressed clients with significant trauma histories may find that clearly distinguishing BPD and cPTSD can increase their precision in assessing and formulating treatment plans to address complex forms of affect dysregulation and dissociation which often accompany the trauma-related hypervigilance and dissociative features of PTSD. These findings raise the possibility that affect dysregulationparticularly under-regulation of affect due to impaired adaptive strategies and high levels of distress intolerancemay be a marker for a sub-group among BPD-diagnosed persons distinct from the majority who also struggle with affect dysregulation but tend to be tonically tolerant of distress and intermittently overwhelmed. J Affect Disord 2013,147(13):7279. 2017;17(1):221. doi:10.1186/s12888-017-1383-2, Giourou E, Skokou M, Andrew SP, Alexopoulou K, Gourzis P, Jelastopulu E. Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma?. Adults with BPD also are at risk for abuse or re-victimization in adulthood [66, 67, 82], and cumulative poly-victimization across the lifespan [39, 66, 67, 70, 82]. Thomaes K, Dorrepaal E, Draijer NP, de Ruiter MB, Elzinga BM, van Balkom AJ, Veltman DJ. For example, BPD diagnosed adults did not evidence a distinct pattern of physiological emotional processing despite being physiologically activated in response to interpersonal challenge scripts compared to those diagnosed with obsessive-compulsive disorder [184]. Psychiatry Res 2010,181(2):151154. When these disorders and severe impairments occur as comorbidities or features of BPD [19, 24, 60, 9193], these complex cases tend to be particularly chronic, dangerous, and treatment-refractory [8, 9, 94100]. Psychol Med 2010,40(5):847859. A common denominator across the newer PTSD features also is central to BPD: under-regulation of extreme negative affect states [35, 36, 158, 159]. 2021 Oct 14;9(10):1469. doi: 10.3390/biomedicines9101469. The deficits in adaptive emotion regulation and problems with impulsivity and avoidance/self-medication characterizing this putative sub-group are consistent with descriptions of cPTSD. New York: Routledge; 2012. Frisman LK, Ford JD, Lin H, Mallon S, Chang R: Outcomes of trauma treatment using the TARGET model. Thus, cPTSD may serve as a sub-type of BPD in which profound developmental trauma causes, or creates a vulnerability to, a range of symptoms and impairments that, in the DSM, results in multiple comorbid diagnoses. doi:10.1080/15299732.2011.620687, Spiegel D, Loewenstein RJ, Lewis-Fernandez R, Sar V, Simeon D, Vermetten E, Dell PF: Dissociative disorders in DSM-5. Affect dysregulation (specifically, distress intolerance and deficits in adaptive emotion regulation and emotion clarity) were shown to account for the shame-based [181] heightened fear of social rejection in adults diagnosed with BPD [51, 52]. The ISTSS expert consensus treatment guidelines for complex PTSD in adults; 2012. Advances in empirically-supported treatment for both PTSD and BPD illustrate how an integrative cPTSD framework can yield therapeutic advances. Zanarini MC, Frankenburg FR, Fitzmaurice G. Defense mechanisms reported by patients with borderline personality disorder and axis II comparison subjects over 16years of prospective follow-up: description and prediction of recovery. doi:10.1016/j.neuropharm.2011.04.028, Geuze E, Westenberg HG, Jochims A, de Kloet CS, Bohus M, Vermetten E, Schmahl C: Altered pain processing in veterans with posttraumatic stress disorder. FOIA J Am Acad Child Adolesc Psychiatry 1995,34(5):541565. [Comparative Study Research Support, Non-U.S. Govt]. Emotion regulation is known to be founded on developmental attainments (e.g., emotion self-awareness, empathy, self-control) that are profoundly influenced by interaction with primary caregivers beginning in infancy and extending through childhood [197]. doi:10.1093/scan/nsr084, Cardenas-Morales L, Fladung AK, Kammer T, Schmahl C, Plener PL, Connemann BJ, Schonfeldt-Lecuona C: Exploring the affective component of pain perception during aversive stimulation in borderline personality disorder. Conclusions: McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC: Childhood adversities and adult psychopathology in the National Comorbidity Survey Replication (NCS-R) III: associations with functional impairment related to DSM-IV disorders. Common factors in empirically supported treatments of borderline personality disorder. Rather than fitting recipients to the therapy, this approach to treatment research matches therapies to recipient characteristics when this is necessary to reduce the number needed to treat for successful outcomes. Both over- and under-regulation of affect have been shown to be associated with BPD symptom severity [182], and under-regulation of affect has been shown to be associated with BPD diagnoses as well as to account for the relationship of childhood maltreatment history and chronic negative affect with BPD [183]. Having Both PTSD & Borderline Personality Disorder. J Trauma Stress 1997,10(4):539555. Psychol Med 2014. doi:10.1017/S003329171300250X, Jovanovic T, Ressler KJ: How the neurocircuitry and genetics of fear inhibition may inform our understanding of PTSD. Assion HJ, Brune N, Schmidt N, Aubel T, Edel MA, Basilowski M, Frommberger U: Trauma exposure and post-traumatic stress disorder in bipolar disorder. doi:10.1037/a0018493. Br J Psychiatry 2009,195(4):325330. Epub 2020 Oct 1. The role of traumatic stress in the etiology and phenomenology of Borderline Personality Disorder (BPD) has received substantial attention [6] because BPD poses particularly difficult clinical challenges consistent with the developmental aberrations associated with developmental trauma [79]. In fact, all of the new or revised PTSD symptoms that potentially overlap with BPD features are cardinal features of cPTSD: affect dysregulation, altered core beliefs about self, reckless or dangerous impulsive behavior, self-harm. Neuropharmacology 2012,62(2):586597. Social problem solving, autobiographical memory, trauma, and depression in women with borderline personality disorder and a history of suicide attempts. J Affect Disord 2013,144(12):7278. Psychol Med 2012,42(11):23952404. (2017). Careers. Bierer LM, Yehuda R, Schmeidler J, Mitropoulou V, New AS, Silverman JM, Siever LJ: Abuse and neglect in childhood: relationship to personality disorder diagnoses. Review. Differentiating symptom profiles of ICD-11 PTSD, complex PTSD, and borderline personality disorder: A latent class analysis in a multiply traumatized sample. Soc Psychiatry Psychiatr Epidemiol 2009,44(12):10411049. Zanarini MC, Frankenburg FR, Reich DB, Hennen J, Silk KR. Acta Psychiatr Scand 2012,125(5):388399. Most of the inpatients (80%) had childhood exposure to sexual and/or physical abuse, but this was true of all of the comorbid BPD-DID patients and their trauma severity scores (including number of types, perpetrators, and duration of abuse) were 50% (vs. DID only) to 100% (vs. BPD only or other psychiatric disorders) higher than other patients. Size abnormalities of the superior parietal cortices are related to dissociation in borderline personality disorder. Cloitre M, Koenen KC, Cohen LR, Han H. Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse. Findings supported the construct validity of Complex PTSD as distinguishable from BPD. Impact of co-occurring posttraumatic stress disorder on suicidal women with borderline personality disorder. Zanarini MC, Gunderson JG, Marino MF, Schwartz EO, Frankenburg FR: Childhood experiences of borderline patients. More specifically, a systematic comparison of how the three syndromes differ on the National Institute of Mental Healths Research Domain Criteria (RDOCs) [218] could clarify the syndromes construct validity (or lack thereof) and point toward clinical and translational studies of targeted assessment, diagnostic, and therapeutic protocols. Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: findings from the collaborative longitudinal personality disorders study. Plus Coping Methods, Debra Rose Wilson, PhD, MSN, RN, IBCLC, AHN-BC, CHT. Lei H, Nahum-Shani I, Lynch K, Oslin D, Murphy SA. Complex PTSD and borderline personality disorder. doi:10.1371/journal.pone.0065824. Complex PTSD is characterised by Spinazzola J, Ford JD, Zucker M, van der Kolk BA, Silva S, Smith SF, Blaustein M: National survey on complex trauma exposure, outcome, and intervention among children and adolescents: errata. Complex PTSD: what is the clinical utility of the diagnosis? Alterations in default mode network connectivity during pain processing in borderline personality disorder. Curr Psychiatr Rep 2009,11(1):6368. CAS Pre/early adolescent children with histories of emotional abuse were found to be at risk for developing BPD symptoms only if they also had problems with under-regulated affect and impulsivity [188]. BPD also was found to be associated with difficulty in recognizing emotions and distinguishing self-referential beliefs from reality, while anxiety and affective disorders were associated with difficulty in experiencing emotions and somatoform disorders were characterized by a deficit in self-referential beliefs. Similarly, ACC hypo-activation occurred when individuals diagnosed with BPD underwent a physical pain induction, although they showed decreased rather than increased amygdala and insula activation, increased dorsolateral PfC activation, andof notedissociative analgesia [116]. http://scholar.google.com.au/citations?view_op=view_citation%hl=en%user=z6lcOR0AAAAJ%26cstart=20%citation_for_view=z6lcOR0AAAAJ:M3ejUd6NZC8C, Bardeen JR, Dixon-Gordon KL, Tull MT, Lyons JA, Gratz KL: An investigation of the relationship between borderline personality disorder and cocaine-related attentional bias following trauma cue exposure: the moderating role of gender. Structured Therapy for Affective and Interpersonal Regulation with Modified Prolonged Exposure (STAIR-MPE) provides a DBT-informed first phase of therapy aimed at enhancing affect and interpersonal regulation skills, followed by a modification of PE similar to that in DBT+PE which carefully titrates trauma memory processing intensity to not exceed the clients affect regulation capabilities. J Psychiatry Neurosci 2012,37(4):241249. Treatment for BPD, such as dialectical behavior therapy (DBT) may also reduce PTSD symptoms. Clinicians evaluating severely distressed clients with significant trauma histories may find that clearly distinguishing BPD and cPTSD can increase their precision in assessing and formulating treatment plans to address complex forms of affect dysregulation and dissociation which often accompany the trauma-related hypervigilance and dissociative features of PTSD. doi:10.1521/pedi_2012_26_062. In addition, there may be emotional numbing and a lack of ability to experience pleasure or positive emotions. A similarly sizable (i.e., 40-50%) sub-group of individuals with BPD also reported clinically significant dissociation, almost always in combination with affect dysregulation [158, 159]. van Dijke A, Ford JD, Van der Hart O, van Son M, Van der Heijden P, Buhring M. Affect dysregulation in borderline personality disorder and somatoform disorder: differentiating under- and over-regulation. For example, in the RDOC negative valence systems PTSD should be particularly associated with acute or sustained threat and BPD with frustrative nonreward, while the two would be expected to overlap on the criteria of anxiety and loss, across the range of units of analysis from genes to physiology to behavior and self-report. They may also: CPTSD and BPD may increase your chance of self-harm. Weniger G, Lange C, Sachsse U, Irle E. Reduced amygdala and hippocampus size in trauma-exposed women with borderline personality disorder and without posttraumatic stress disorder. OBrien BS, Sher L. Child sexual abuse and the pathophysiology of suicide in adolescents and adults. Preliminary evidence for sensitive periods in the effect of childhood sexual abuse on regional brain development. In nationally representative samples in the United States, approximately 30% of adults meeting criteria for either PTSD or BPD also met criteria for the other disorder, and closer to 40% of adults diagnosed with BPD had an episode of PTSD at some point in their lifetime [19]. sharing sensitive information, make sure youre on a federal Most cases of Axis I and II disorders do not have comorbid BPD: the highest BPD comorbidity rates are 50% for eating disorders [24], 30-35% for SUD or bipolar disorder, and 25-50% for paranoid, avoidant, dependent, and schizotypal personality disorders. University of Connecticut Health Center MC1410, 263 Farmington Avenue, Farmington, CT, 06030-1410, USA, Independent Pactice, Washington, DC, Elements Behavioral Health, Promises, Malibu, CA, USA, You can also search for this author in doi:10.1007/s0012700900291, Strawn JR, Adler CM, Fleck DE, Hanseman D, Maue DK, Bitter S, DelBello MP: Post-traumatic stress symptoms and trauma exposure in youth with first episode bipolar disorder. Eur Arch Psychiatry Clin Neurosci 2014,264(1):4560. J Abnorm Psychol 2008,117(3):502519. But the International Classification of Diseases, 11th edition (ICD-11), used by the World Health Organization (WHO) and many clinicians, considers CPTSD a different category of PTSD. doi:10.4088/JCP.12m08030, First MB: Clinical utility: a prerequisite for the adoption of a dimensional approach in DSM. An official website of the United States government. Please enable it to take advantage of the complete set of features! BPD and PTSD are relatively distinct with regard to the precise qualitative definitions of their diagnostic features, but nevertheless have substantial potential overlap in their symptom criteria. BPD is part of a group of mental disorders referred to as personality disorders by the5th edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-5). Although, as noted above, the DSM-5 PTSD criteria have been expanded to include aspects of affect, relational, and self-dysregulation, the emphasis in PTSD remains upon re-experiencing and hypervigilance with dysregulation not a fully delineated as in cPTSD and BPD. But a single traumatic event can also cause CPTSD. Ups J Med Sci. In both BPD and PTSD secondary to childhood maltreatment, under-regulation of affect are marked by inability to recover from episodes of chronic intense negative affect [75, 121] and dissociation [7]. The role played by PTSD or childhood traumatic victimization in dissociation in BPD has not been definitely established. J Trauma Stress. Cardenas-Morales L, Fladung AK, Kammer T, Schmahl C, Plener PL, Connemann BJ, Schonfeldt-Lecuona C. Exploring the affective component of pain perception during aversive stimulation in borderline personality disorder. doi:10.1002/jclp.20396, Gratz KL, Tull MT: Exploring the relationship between posttraumatic stress disorder and deliberate self-harm: the moderating roles of borderline and avoidant personality disorders. However, in PTSD, pain-related impairment, hyperalgesia rather than analgesia, is prominent. A study with college students found that having valued relationships outside the family in the larger community statistically mediatedand mitigated againstthe risk of developing BPD traits associated with a history of exposure to childhood betrayal trauma [203]. What Is Borderline Personality Disorder (BPD)? (2016). If cPTSD was primarily or only a sub-type of BPD, then BPD should be present in all high trauma burden Axis I and II disordersbut this is not the case. If youre considering self-harm or suicide, youre not alone. Pursuing that question, a study compared psychiatric inpatients diagnosed with BPD to those with severe somatoform or mood/anxiety disorders and found that the BPD cases were most likely to report traumatic victimization by a primary caregiver and severe under-regulation of affect [35, 36]. Borderline Personality Disorder and Emotion Dysregulation, http://creativecommons.org/licenses/by/4.0, http://creativecommons.org/publicdomain/zero/1.0/. CPTSD includes all the symptoms of PTSD plus additional symptoms that include a negative self-image, difficulty regulating emotions, and problems with interpersonal relationships. Borderline personality disorder and childhood trauma: evidence for a causal relationship. cPTSD was assessed in that psychiatric inpatient study as well [35, 36]. The trauma causes both groups to alienate to some degree from others, mood swings (intense highs and low), panic from abandonment, and concentration issues. Experts can find other similarities by looking at the ways victims react when they have either of these diagnoses. Ford JD, Smith S: Complex posttraumatic stress disorder in trauma-exposed adults receiving public sector outpatient substance abuse disorder treatment. Complex post-traumatic stress disorder (complex PTSD) is a severe mental disorder that emerges in response to traumatic life events. Borderline Personal Disord Emot Dysregul. Am J Psychiatr 2010,167(7):748751. If you have borderline personality disorder, you may often feel intense emotions and have trouble controlling your behavior as a result. Bookshelf [Comparative Study Research Support, U.S. Govt, P.H.S.]. The implications and unanswered questions raised by these findings will next be discussed. Assessment 2008,15(4):404425. Borderline Personal Disord Emot Dysregul. Borderline Personal Disord Emot Dysregul. Moreover, BPD has a multi-factorial etiology, and trauma is only one of many potential risks or contributors. Zimmerman M, Mattia JI: Axis I diagnostic comorbidity and borderline personality disorder. Daniels JK, McFarlane AC, Bluhm RL, Moores KA, Clark CR, Shaw ME, Lanius RA: Switching between executive and default mode networks in posttraumatic stress disorder: alterations in functional connectivity. Adults diagnosed with BPD have been shown to be more likely than adults with other psychiatric or personality disorders or no psychopathology to report a history of psychological trauma [5, 6570]. doi:10.1111/pme.12260, Powers A, Fani N, Pallos A, Stevens J, Ressler KJ, Bradley B: Childhood abuse and the experience of pain in adulthood: the mediating effects of PTSD and emotion dysregulation on pain levels and pain-related functional impairment. BPD has been shown to involve deficits in social cognition related to dichotomous thinking, distrust, aggressive attributions, and increased attention to, but impaired recognition, understanding, and empathy for, others emotions, thoughts, and intentions. In: Courtois CA, Ford JD, editors. doi:10.1016/j.beth.2012.10.003, Ford JD, Grasso D, Greene C, Levine J, Spinazzola J, van der Kolk B: Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians. [Research Support, N.I.H., Extramural Research Support, Non-U.S. Govt]. 2016;3:7. doi:10.1186/s40479-016-0042-4, Ekselius L. Personality disorder: A disease in disguise. doi:10.1097/0000458319950500000008, Kim-Spoon J, Cicchetti D, Rogosch FA: A longitudinal study of emotion regulation, emotion lability-negativity, and internalizing symptomatology in maltreated and nonmaltreated children. The complexity of complex PTSD. However, if assessment indicated the presence of affectively charged (or incongruously emotionally numbed) schemas representing self and relationships as simultaneously irreparably damaged but essential and irreplaceable, and this conflict was associated with affective over- as well as under-regulation, cPTSD offers a unique focus distinct from that of either BPD or PTSD. doi: 10.1521/psyc.2013.76.4.365. Compr Psychiatry 2010,51(3):275285. Treating Complex Trauma: A Sequenced Relationship-Based Approach. When pilot tested with women meeting criteria for comorbid BPD and PTSD, the trauma-informed DBT yielded similar completion rates (67-70% when therapists had acceptable fidelity) and better outcomes for self-harm, depression, anxiety, guilt, and shame than DBT alone [210]. doi:10.1111/j.13600443.2010.03176.x, Zanarini MC, Horz S, Frankenburg FR, Weingeroff J, Reich DB, Fitzmaurice G: The 10-year course of PTSD in borderline patients and axis II comparison subjects. Eur Arch Psychiatry Clin Neurosci 2013,263(7):575583. Loneliness and needing to self-isolate are common in people with BPD but there are steps you can take to move toward connection and healing. Affect dysregulation in adolescence and adulthood correspondingly has been found to be associated with childhood relationships with primary caregivers who are unresponsive, poorly attuned, or punitive [90]. 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