Borderline personality disorder (BPD) and complex post-traumatic stress disorder are both mental health diagnoses that are closely related to trauma, especially early-life trauma. The associations between BPD and complex trauma are so strong that some experts argue that cPTSD and BPD are actually the same condition. In Australia, some clinicians prefer to give a cPTSD diagnosis because of the stigma that sadly still surrounds borderline personality disorder.
However, studies comparing the two sets of symptoms show that, while they overlap, they are distinct conditions that may require different treatments. Providing an accurate diagnosis that reflects a young person’s experiences is essential for effective treatment and recovery. We need to challenge the stigma around BPD that prevents access to effective care and support, rather than overlooking the diagnosis.
Regardless of the diagnosis a young person has, effective treatment is available. There are several evidence-based treatment approaches for both BPD and cPTSD, proven to improve symptoms and help young people lead fulfilling and productive lives.
This blog explores the similarities and differences between borderline personality disorder and complex PTSD, and what is needed to make an accurate diagnosis. It also offers some information on the medical and social context in Australia, and how this can impact diagnostic practices.
What Is Borderline Personality Disorder?
Borderline personality disorder is a type of personality disorder where someone experiences unstable emotions, relationships, and a sense of self. Young people with borderline personality disorder may have intense and quickly changing emotions that are difficult to soothe, especially in response to things that happen in relationships. They may have a strong fear of abandonment, feelings of emptiness, and patterns of impulsive behaviours.
Importantly, having a personality disorder doesn’t mean there is something wrong with someone’s personality. It just means that they feel and act in ways that are different from other people and can make daily life difficult to manage. Often, these behaviours have developed as coping mechanisms for difficult early life experiences, which may have been protective at the time but become maladaptive later on in life.
What Is Complex PTSD?
Complex PTSD is a mental health disorder that can develop after someone experiences ongoing, repeated trauma, most often during their childhood. Most instances of complex trauma are interpersonal in nature, involving abuse, neglect, war, or exposure to violence. Complex trauma sometimes develops when caregivers are unable to meet a child’s emotional and physical needs because of stress in the family, social hardships, or their own mental health challenges.
Young people with cPTSD have symptoms of PTSD, such as flashbacks and hypervigilance (being on constant high alert), alongside other traits, including mistrust of others, hopelessness, feelings of worthlessness, and intense emotions that are difficult to calm.
Complex PTSD still isn’t listed as a separate diagnosis in the DSM-5; instead, the criteria for a PTSD diagnosis were broadened to include some cPTSD features. However, empirical evidence suggests that cPTSD has distinct core elements from PTSD. It’s now recognised as a separate diagnosis in the International Classification of Diseases (ICD-11).
How Are BPD and cPTSD Related to Trauma?
Borderline personality disorder and complex post-traumatic stress disorder are both strongly linked to childhood trauma. While experiences of complex trauma are included in the diagnostic criteria of cPTSD, they are not necessary for a BPD diagnosis. However, research suggests that 85% of people with a BPD diagnosis report experiences of childhood trauma. This figure may be even higher in reality, as some people who have survived trauma may not remember it or identify it as such.
Research suggests that both BPD and cPTSD develop when difficult early life experiences, especially interpersonal trauma, disrupt a young person’s social and emotional development. When children are exposed to ongoing threats, they use networks in the brain associated with survival, responding to perceived danger with fight, flight, or freeze responses. These networks bypass processes of self-reflection to enable faster reactions to a threat.
But overusing these networks can limit opportunities for other skills to develop, such as problem-solving, mentalising, self-reflection, and emotional processing. At the same time, a lack of secure relationships with caregivers can also prevent children from learning the skills they need to navigate everyday life.
On a neurobiological level, both cPTSD and BPD are associated with dysregulation of stress response systems, including the HPA axis. When children experience ongoing, high levels of stress, without a responsive caregiver who is able to soothe them, it shapes the way their stress response systems work in the future.
These networks can become overreactive, triggering heightened and prolonged stress responses to events that may not actually be threatening. As they grow older, they may respond to normal events in relationships with anxiety, fear, or anger. This can explain some of the symptoms and traits of cPTSD and BPD.
Why Do Some Australian Clinicians Prefer to Diagnose a Young Person With cPTSD?
Some clinicians are reluctant to give a BPD diagnosis because of the stigma associated with the disorder. Young people in Australia who are diagnosed with BPD often face heavy stigma from clinicians, employers, and even friends and family. Borderline personality disorder is the most stigmatised of any mental health disorder.
Although research clearly shows otherwise, some medical professionals still think of borderline personality disorder as a set of difficult behaviours that are “chosen” by the individual, rather than a group of coping mechanisms and emotions that have developed as a result of trauma. This can cause additional distress, exclusion, low self-esteem, and isolation among people with BPD.
It can also prevent people with a BPD diagnosis from accessing effective treatment: many clinics in Australia only prescribe anti-psychotic and anti-depressant medications as BPD treatment, rather than offering psychotherapy that addresses the underlying causes of BPD by developing skills like emotional regulation, distress tolerance, and mentalisation.
Some clinicians believe that diagnosing young people with cPTSD instead of BPD will reduce the stigma they face and enable access to more effective treatment and care. They think that the diagnosis of cPTSD better emphasises young people’s behaviours as a response to traumatic experiences, rather than an inherent, unchangeable, and core part of who they are.
How Are Borderline Personality Disorder and Complex Post-Traumatic Stress Disorder Different?
However, while complex PTSD may be less stigmatised than BPD, there are distinct differences between the two disorders. This means that diagnosing a young person who has BPD with cPTSD can overlook or mischaracterise parts of their experience. This may become a different kind of barrier to effective care.
Both cPTSD and BPD include symptoms and traits in three main areas: emotional dysregulation, interpersonal difficulties, and sense of self and identity. But the specific symptoms of the two disorders are different.
For example, challenges with emotional regulation in cPTSD tend to involve difficulties soothing distressing feelings or persistent emotional numbness. On the other hand, emotional regulation difficulties in ΒPD are often broader, also including intense anger and other emotional reactions that are hard to control.
Equally, while young people with cPTSD often experience stable feelings of shame, low self-worth, and emptiness, BPD is characterised by an unstable, incoherent, or quickly changing sense of self and identity. And while both cPTSD and BPD involve interpersonal difficulties, in BPD, this tends to include a fear of abandonment and patterns of idealisation and devaluation that are not core features of cPTSD.
Not all studies have concluded that BPD and cPTSD are distinct conditions: some studies have suggested that BPD may be a more complex form of PTSD. However, taken together, the research we have today suggests they are two separate disorders with overlapping symptoms.
Research exploring the overlap and differences between cPTSD and BPD symptoms has found that:
- BPD was characterised by emotional reactivity, impulsivity, feelings of emptiness, fear of abandonment, and a fragmented and unstable sense of self
- PTSD was characterised by fear-related intrusive memories, hypervigilance, and avoidance
- Both PTSD and BPD were associated with experiences of trauma, but people with BPD tended to have a more complex trauma history
How Can Clinicians Make a Reliable Diagnosis of cPTSD or BPD in Young People?
Distinguishing BPD and cPTSD requires a comprehensive understanding of a young person’s traits, behaviours, and experiences. This means, for example, not only identifying that a young person struggles with emotional dysregulation, but also understanding what form it takes. If their distress is more connected to a general perception of threat, it may be a marker of cPTSD, while distress triggered by a fear of abandonment is more associated with BPD.
Understanding a young person’s relationship patterns is also important. If they have a history of withdrawal or detachments in relationships, rather than, or as well as, emmeshment and intensity, it can be a sign of cPTSD. Stable self-perception, rather than a fragmented sense of self, may also be a key marker.
It’s important to consider cPTSD, perhaps alongside BPD, if a young person has a history of different kinds of victimisation, maltreatment, disorganised attachment, and frequent dissociation. Clinicians should keep in mind that cPTSD symptoms often appear in addition to and alongside borderline personality disorder, and can create additional challenges in navigating daily life.
Gaining these insights may involve asking for a comprehensive history of relationships, experiences of mistreatment, early-life experiences, and psychological symptoms. For a young person with BPD, such a process can be emotionally destabilising if it’s not delivered with care and sensitivity.
However, if clinicians make these assessments with a calm and non-judgemental approach, person-centred and trauma-centred assessments can help to build a narrative that shows how symptoms and traits emerged in response to trauma and adversity. Forming this narrative collaboratively can be an important step in building a trusting relationship between a young person and their therapist that’s founded in genuine interest and care.
How Can Effective Treatment Lead to Hope and Recovery for Young People?
Whatever diagnosis fits a young person’s experience, there are opportunities for wellness and fulfilment. With effective treatment, young people can recover from cPTSD, BPD, and co-occurring cPTSD with BPD and thrive in everyday life.
Treatment for borderline personality disorder usually involves a combination of psychotherapies, social support, and occupational support. There are several kinds of psychotherapy proven to effectively treat BPD, including:
- Dialectical behavioural therapy
- Mentalisation-based therapy
- Schema therapy
- Transference-focused therapy
- Family therapy
- Acceptance and commitment therapy
For complex trauma, psychotherapies include:
- Trauma-focused cognitive behavioural therapy
- Seeking safety therapy
- Dialectical behavioural therapy
- Eye movement desensitisation and reprocessing therapy
Young people living with co-morbid cPTSD and BPD, or BPD with cPTSD symptoms, may benefit from combining BPD treatments with PTSD and cPTSD treatments. This might involve participating in multiple therapies at the same time, or combining elements of different therapies in a treatment program. For example, some clinical trials have combined dialectical behavioural therapy with elements of prolonged exposure therapy (a trauma treatment) or eye-movement desensitisation and reprocessing therapy.
The Wave Clinic: Transformative Mental Health Support for Young People and Families
The Wave Clinic offers specialist residential and outpatient mental health support for borderline personality disorder, complex trauma, and other mental health concerns. We provide a diverse selection of evidence-based modalities, delivered by experts in child and adolescent psychiatry from around the world.
Our programs are trauma-focused, sensitively addressing experiences of trauma from the start of any treatment program. We also take a trauma-focused approach to family interventions, exploring how family trauma can lead to harmful dynamics in family systems and creating new ways of relating through therapy and new experiences.
We work to challenge the stigma surrounding borderline personality disorder and mental health more broadly. We focus on understanding each young person’s story, experiences, and gifts, helping adolescents and young adults build the futures they dream of.
If you’re interested in finding out more about our programs, get in touch today.
