Let’s face it:
Complex Trauma (cPTSD) lends itself to more immediate understanding and validation than the term “personality disorder.” The term “borderline” has also been used as a derogatory adjective, mostly by mental health professionals, and is often misunderstood by clients to mean that one has multiple personalities by “bordering” on one personality versus another. It’s confusing. Borderline Personality Disorder (BPD) has been stigmatized for decades because of persistent ignorance toward the diagnosis and corresponding research by Dr. Marsha Linehan. It’s helpful that the mental health field is finding new ways to describe BPD, specifically highlighting its origin and expression of complex trauma. I think clients themselves have been masters of the movement, advocating to have their experiences legitimized and embraced into a community of trauma survivors.
All of the clients (yes, all!) I’ve treated with BPD very much resonate with the diagnosis and hold it in high regard. Usually, this comes after years of feeling invalidated and left untreated within the mental health system. However, this can only occur when diagnosing is done over a longer-term therapeutic relationship, with professional expertise and psychoeducation, compassion, and guidance as to how Dialectical Behavioral Therapy (DBT) can truly eliminate symptoms.
cPTSD consists of symptoms different than the more traditional diagnosis of Post-Traumatic Stress Disorder (PTSD). They include:
• Affect dysregulation
• Flashbacks (re-experiencing)
• Insomnia + nightmares
• Interpersonal disturbances
• Avoidance
• Negative self-concept
• Hypervigilance/sense of threat
• Dissociative tendencies
The most helpful way to describe the symptoms of BPD include:
• Affect dysregulation (+ anger)
• Frantic efforts to avoid abandonment
• Interpersonal disturbances
• Impulsivity/self-defeating behavior
• Negative self-concept
• Emptiness
• Suicidal ideation
• Dissociative tendencies
Frantic efforts to avoid abandonment, strong anger, impulsivity and/or self-defeating behavior, a chronic sense of emptiness, and suicidal ideation are the specific symptoms that can separate BPD from cPTSD per se, but only in their level of magnitude and frequency. Therefore, whether one receives a diagnosis of cPTSD or BPD is really just a matter of severity. For instance, a more physiological hypervigilance characteristic with cPTSD (and PTSD) is often expressed behaviorally with BPD in a multitude of ways. With both cPTSD and BPD diagnoses, it is absolutely understood by trauma therapists as a completely “normal” response for a brain and body that has endured such “abnormal” events. Dr. Linehan’s research and training challenges mental health professionals to radically accept the often judged and misunderstood behavior in complex trauma as making “perfect sense” given the history of a client.
A huge educational piece that is left out of clinical conversations and corresponding treatment is the biopsychosocial theory of the development of BPD. One will learn the research clearly outlines childhood abuse and emotional neglect as the highest diagnostic precursor. It is widely accepted that cPTSD has its origins in childhood traumatic experience with continued relational wounding or crises within adulthood. The complex nature includes the experiencing of many traumatic events throughout one’s lifetime and corresponding problems with securely attaching to others and oneself.
DBT is the most effective philosophy and treatment modality to address cPTSD and BPD. There are many options in how to facilitate or infuse DBT into a client’s psychotherapy treatment plan, especially if the presenting symptoms are considered lower severity and fall more in line with cPSTD. If the severity of struggle is high with prior unsuccessful treatment episodes, including suicidal ideation, dissociation, and several maladaptive behaviors, there is no question that a more comprehensive DBT program is required for healing.
If you are a trauma survivor and interested in comprehensive assessment, please reach out!
If you are an individual clinician or group practice owner, these are helpful considerations when reflecting upon whether you are interested and qualified to work with complex trauma, which includes clients with BPD.
• Do you specialize in relational trauma?
• Are you marketing to cPTSD?
• Are you interested in modified DBT?
• Do you assess for common co-occurring diagnoses, such as Substance Use Disorders and eating disorders?
• Are you comfortable with chronic suicidal ideation as a treatment target?
I love providing intimate consultation to clinicians or groups interested in learning more. The general training I provide focuses upon the overlap between cPTSD and BPD, the biopsychosocial theory of BPD, criteria for diagnosing to include identification of underlying behavioral patterns and secondary targets for treatment, and other assessment strategies. We also talk about the philosophical underpinnings of DBT, which are what makes work with BPD so effective, rich and fulfilling. For groups and organizations interested in developing comprehensive DBT programming, we take a deeper dive into dialectical tensions, evidenced-based protocols, clinical interventions, and factors to consider when implementing the Skills Training group therapy portion.
Thankfully, BPD has been rebranded.