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Post-Traumatic Stress Disorder

BPD vs. Complex PTSD: What Is the Difference?

How we define an illness may dictate how we treat it.

Key points

  • Complex PTSD refers to specific symptoms derived from exposure to prolonged, repeated trauma.
  • Symptoms of BPD and CPTSD are similar, but it is unclear how best to categorize these diagnoses.
  • The most important approach to a mental illness is deciding how best to treat it.

Complex post-traumatic stress disorder (CPTSD) was first proposed 20 years ago by Judith Herman as a diagnosis separate from PTSD. Whereas PTSD is formally defined by reactions to a single traumatic event (and in today’s culture has become a popularized term referring to upset feelings about almost anything), CPTSD refers to specific symptoms derived from exposure to prolonged, repeated trauma. Most often, this results from longstanding physical or sexual abuse, resulting from imprisonment or childhood cruelty.

Resultant symptoms, in addition to those of PTSD, comprise identity disturbance, dissociative experiences, poor relationships, mood disorder, suicidal thoughts and self-destructive behavior, feelings of worthlessness, anger, and other symptoms of borderline personality disorder (BPD). CPTSD has not yet been formally accepted as a separate diagnosis in either DSM-5 or ICD-11.

The overlap between BPD and CPTSD begs the question: Are these separate disorders, or are we viewing the same entity? Taxonomy considerations debate splitting (separating diagnoses) or lumping (combining diagnoses). Splitters argue that the designations are separate: One diagnosis is related to trauma, and the other is a personality disorder, which may not involve a clear history of trauma. Lumpers maintain the symptoms are the same. Indeed, a past argument maintained that BPD should be characterized as a form of PTSD and not as a personality disorder at all, although today symptomatic, biological, and heritability factors maintain distinctions.

How we label this collection of symptoms is relevant for two primary considerations: how to understand the disorders and how best to treat them. Since CPTSD includes disruption in characterological functioning, it must, at least in part, be perceived as a disorder of personality, like BPD. Both diagnoses are almost always co-morbid with other illnesses, especially depression, anxiety, and substance use disorders. Therefore, both will usually require treatment with medications and some form of psychotherapy.

Several formalized therapy programs have been devised for the treatment of BPD. These include cognitive behavioral therapy (CBT) and derivatives including dialectical behavioral therapy (DBT), which are the most studied. Other therapies are mentalization-based therapy (MBT), transference-focused therapy (TFP), schema-focused therapy (SFT), and others.

Treatment of PTSD has mostly involved CBT techniques that attempt to reprocess reactions to the trauma. Other documented therapy approaches have included exposure therapy and eye movement desensitization and reprocessing (EMDR). These are focused on re-experiencing the traumatic event. CPTSD treatment may require a different approach, since it derives not from exposure to a discrete episode, but to long-standing mistreatment. Therapy that attempts to maintain attention on this abuse may be more likely to exacerbate symptoms than alleviate them. Instead, treatment methods more like those used for BPD, which help the patient derive more productive coping skills, may be more appropriate for treatment of CPTSD.

In the end, the most vital element in confronting mental illness is what we do about it, not how we label it.

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