For decades the psychiatric diagnostic system in the United States has placed adults struggling with chronic mental health issues as a result of complex trauma in a limited number of narrowly defined boxes.
Most prevalent among these is Posttraumatic Stress Disorder (PTSD). Decades after its establishment as an important diagnosis, at its worst PTSD can be a loosely used label, assigned to the majority of treatment-seeking individuals with a history of trauma. In reality, PTSD is often just the tip of the iceberg, and far from encompasses the breadth or depth of the effects of complex trauma.
Borderline Personality Disorder: The Most Ill-Fitting of Boxes?
Arguably the most problematic box into which many complexly traumatized individuals have been forced is Borderline Personality Disorder (BPD). Far too many trauma survivors have been labeled “borderline,” a term often equated with permanent character defects.
Worse, the assumption is that these personality features simply arise on their own. This can result in harsh judgments about the value of people given this diagnosis. BPD has historically been misused as the unspoken basis to justify the objectification or rejection of a person seeking medical, mental health or social services. When defined by this unforgiving label, individuals who have endured lifetimes of trauma can quickly begin to blame, hate, and give up on themselves.
Selena Gentile, MSW, LSW, LCADC Intern, is Chief Program Officer at The Center for Great Expectations, a New Jersey agency that offers a wide array of behavioral health and substance-abuse treatment services to adults and youth, the majority of whom have extensive histories of complex trauma compounded by economic marginalization, discrimination, and other forms of social oppression. Many of her Center’s clients arrive carrying a diagnosis of BPD.
Comments Ms. Gentile,
“Unfortunately, when people are diagnosed with Borderline Personality Disorder there is a stigma associated which often equates to being viewed as untreatable and unable to improve in areas such as interpersonal relationships. Since even treatment providers can dismiss those with a diagnosis of Borderline Personality Disorder, this new research which assists in appropriately informed diagnoses, will provide hope for an improved future and better treatment outcomes for those who have experienced complex trauma.”
A Different Frame for Adults Impacted by Complex Trauma
Clinical research is helping to dismantle the boxes of outdated diagnostic systems, providing hope for clients with complex adaptations of their trauma. In the early 1990’s, Dr. Judith Herman proposed a new diagnosis to capture the array of symptoms and difficulties observed in adult survivors of childhood trauma: Complex-Posttraumatic Stress Disorder (C-PTSD). Efforts around that time to add C-PTSD as a formal psychiatric diagnosis in the United States were thwarted.
Thanks to an impressive body of international research over the past fifteen years, spearheaded by Dr. Marylene Cloitre, there is now compelling scientific evidence for the existence of Complex-PTSD.
This evidence spans studies on diverse clinical populations, cultures and trauma history profiles. C-PTSD encompasses the fear-based responses of PTSD but also includes difficulties with:
- emotion regulation,
- negative self-image and
- adult relationships caused by exposure to complex trauma, especially from chronic or severe maltreatment beginning in childhood.
C-PTSD is slated for inclusion in the next edition of the International Classification of Diseases (ICD-11), the primary diagnostic system used around the world.
Complex-PTSD Distinguished from Borderline Personality Disorder
Clinical writing from the early 2000’s by Dr. Joseph Spinazzola and colleagues distinguished the clinical profiles of adults with C-PTSD from BPD. Nevertheless, resistance to embracing the C-PTSD diagnosis by some factions in the mental health field may be attributable in part to lingering beliefs that C-PTSD is merely an amalgam of PTSD and BPD. These earlier clinical insights have finally been substantiated by several studies that empirically differentiate C-PTSD from these other disorders.
In these studies, BPD was found to be best characterized by frantic efforts to avoid abandonment, a persistently unstable sense of self, unstable and intense relationships including alternating extremes of idealization and devaluation, and impulsiveness including frequent self-harm or suicidal gestures. These symptoms were found to occur with or without history of trauma or associated symptoms of PTSD.
C-PTSD was not found to be associated with any of the symptoms most strongly linked to BPD. In contrast to BPD, C-PTSD was best predicted by difficulties with emotion regulation including problems with:
- anger and hurt feelings,
- negative self-concept including feelings of worthlessness and guilt, and
- interpersonal problems pertaining to feeling disconnected or not close to others.
C-PTSD was associated with co-occurring symptoms of PTSD, and was rarely observed in adults lacking a history of interpersonal trauma.
These studies demonstrate that a diagnosis of PTSD alone is insufficient to clarify the distinction between Borderline Personality Disorder and clinical symptoms driven by complex trauma exposure. Rather, they indicate that a diagnosis of C-PTSD is necessary to fill the gap in understanding the relationship between complex trauma exposure and adaptation.
Right Diagnosis, Right Treatment
Complex-PTSD and Borderline Personality Disorder are divergent conceptualizations of psychological and behavioral difficulties.
Each is associated with different assumptions about the change process and distinct approaches to treatment. Mislabeled and misinformed clients saddled with an inaccurate diagnosis can feel permanently damaged and ashamed, and lost about how to change their lives for the better. In these situations, the risk of being enrolled in ineffective treatment is high. This research may help to turn the tide.
The C-PTSD diagnosis can help reframe self-understanding and societal attributions about the maladaptive coping behaviors and interpersonal challenges experienced by many complexly traumatized adults.
Dr. Mandy Habib, Director of the national Complex Trauma Treatment Network elaborates:
“Clients are displaying symptoms related to their traumatic experiences but when these symptoms are viewed in the absence of a complex trauma lens, we run the risk of implementing treatments that are ineffective for their condition and do not fully capture the impact of their trauma history, nor the function of their behaviors, which oftentimes are an effort to cope with the legacy of their life histories. Establishing an accurate diagnosis for adults with histories of complex childhood trauma is essential, not only to help survivors develop greater self-understanding of the impact of trauma on their lives, but also to help survivors gain greater societal acceptance of their often extreme and self-destructive behaviors.”
Just as importantly, it can guide treatment. Unlike personality disorders, which are believed to have poor treatment prognosis, trauma-related diagnoses have been demonstrated to be highly responsive to treatment. Even adults with histories of extensive trauma, complex symptoms, and poor response to traditional therapies can improve when they discover the treatment that is right for them.
Dr. Habib emphasizes:
“This emerging body of research is critical in the ongoing effort to provide state of the art treatment to survivors of complex trauma. An accurate diagnosis will inform the design and evaluation of new effective intervention models.”
Never Give Up
Recovery from trauma is never hopeless when provided the right diagnosis and offered choices of effective treatment. Understanding complex trauma is the beginning of decreasing stigma, creating change, and improving life prospects for those who have already survived against overwhelming odds.
Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4(1), 20706.
Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis. European Journal of Psychotraumatology, 5(1), 25097.
Dijke, A. V., Hopman, J. A., & Ford, J. D. (2018). Affect dysregulation, psychoform dissociation, and adult relational fears mediate the relationship between childhood trauma and complex posttraumatic stress disorder independent of the symptoms of borderline personality disorder. European Journal of Psychotraumatology, 9(1), 1400878.
Karatzias, T., Shevlin, M., Fyvie, C., Hyland, P., Efthymiadou, E., Wilson, D., . . . Cloitre, M. (2016). An initial psychometric assessment of an ICD-11 based measure of PTSD and complex PTSD (ICD-TQ): Evidence of construct validity. Journal of Anxiety Disorders, 44, 73-79.
Knefel, M., Tran, U. S., & Lueger-Schuster, B. (2016). The association of posttraumatic stress disorder, complex posttraumatic stress disorder, and borderline personality disorder from a network analytical perspective. Journal of Anxiety Disorders, 43, 70-78.
*Several of these articles can be downloaded from the Resources section of this website for free.