Complex Trauma & BPD

There is significant overlap between the symptoms of Complex PTSD and the symptoms of BPD. Individuals who experience C-PTSD or BPD both tend to have emotion regulation issues, conflicts related to identity/sense of self, and difficulty establishing and maintaining healthy relationships. 

ABOUT TRAUMA, PTSD, & C-PTSD

PTSD is defined in the DSM-5, a handbook published by the American Psychiatric Association that is used by mental health clinicians to diagnose mental disorders. According to the DSM-5, trauma can result from direct or indirect exposure to life-threatening experiences i.e. instances wherein one could have died or been seriously injured. The term "trauma" is used to describe both the incident itself as well as the reaction to the incident (i.e. the resulting emotional shock). Trauma can be acute or chronic. Acute trauma refers to a single traumatic incident, such as a serious accident. Chronic trauma refers to repeated or prolonged traumatic incidents, such as ongoing physical abuse. The term "complex" trauma is sometimes used interchangeably with "chronic" trauma, as well as the term is used to describe an individual's reaction to multiple traumatic events. According to the writings of Bessel van der Kolk, a psychiatrist and prominent trauma researcher, complex trauma can result due to exposure to recurring and/or prolonged instances wherein one experiences feelings of intense fear and powerlessness accompanied by the perceived or actual inability to escape. Additionally, complex trauma often refers to traumatic instances that occur within the context of interpersonal relationships. 

In his landmark book on the subject of complex trauma, The Body Keeps The Score, van der Kolk proposed a guideline for Developmental Trauma Disorder (DTD), which describes a trauma-related disorder for children who have experienced complex trauma. Trauma researcher Judith Herman proposed the term Complex Post-Traumatic Stress Disorder or C-PTSD. The criteria for C-PTSD has been newly included the ICD-11, the International Classification of Diseases, which is a system created by the World Health Organization that is utilized by members of various groups (i.e. physicians, policy-makers, researchers) for the purposes of monitoring and reporting on diseases. 

DIAGNOSTIC CRITERIA FOR PTSD  

PTSD is comprised of four symptom clusters including intrusion symptoms, avoidance symptoms, cognition and/or mood-related symptoms, and arousal/reactivity symptoms. Intrusion symptoms are marked by a re-experiencing of the trauma in the present, such as in the form of recurring thoughts or images, feelings of intense psychological distress, or physiological reactions. Avoidance symptoms refer to avoidance of internal stimuli such as trauma-related thoughts or feelings, or avoidance of external stimuli such as people, places, or objects that may evoke trauma-related thoughts or feelings. Cognitive and mood-related symptoms may include experiencing chronic negative emotional state and/or difficulty experiencing positive emotions, holding persistent and extreme negative beliefs about self and others/the world, memory issues, a sense of social alienation and withdrawal from relationships and/or previously enjoyed activities. Arousal/reactivity symptoms refer to the constant sense of present threat that is manifested by an exaggerated startle response, difficulty sleeping, deficits in concentration, and hyper-vigilance, and may also extend to reactions such as physical aggression. 

DIAGNOSTIC CRITERIA FOR C-PTSD

As outlined in the ICD-11, C-PTSD includes intrusion, avoidance, arousal/reactivity symptom clusters as well as the addition of three other symptom clusters that span cognitive, emotional, and interpersonal symptoms. These additional clusters include affect dysregulation, negative self-concept, and disturbances in relationships. Affect dysregulation refers to the experience of having intense and difficult to manage emotions as well as the tendency to detach from emotions (feeling "numb"). Negative self-concept refers to having a belief system or set of narratives about the self that contributes to feelings of worthlessness, defectiveness, incompetence/ineptitude. Disturbances in relationships may include difficulty establishing or maintaining close relationships or the tendency to engage in intense and unstable relationships. 

MY RESPONSIBILITY TO YOU

Individuals with a history of trauma may struggle with various aspects of treatment. If you are prone to dissociative symptoms, you may find that you forget what was discussed in session and you may feel like the sessions lack continuity. If you have relied on dissociation to detach from disturbing emotions in the past, you may find it difficult to access these emotions in session even if you have the desire to do so. Additionally, the therapeutic relationship may feel one-sided at times because a clinician must be prudent about sharing personal information. You may find it difficult to open up in a relationship where sharing is not precisely reciprocated. Or you may notice yourself experiencing thoughts or feelings about the therapy that you recognize as being connected to your past trauma, and I will need you to bring my attention to it so we can better understand it together. My independent learning may tell me how trauma generally affects people, but my goal as a clinician to learn how your trauma affects you. 

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ABOUT BPD: POSSIBLE ENVIRONMENTAL ORIGINS 

According to the writings of Marsha Linehan, individuals who grow up in an environment marked by chronic invalidation tend to develop the traits and symptoms associated with borderline personality disorder. In an invalidating environment, children receive the message that their thoughts and feelings are "wrong," which they may interpret to mean that they are inherently defective on a core level. Trauma exposure is not required to meet the diagnostic criteria for BPD, but many individuals who develop BPD have also been exposed to trauma. 

ANXIETY MANIFESTING IN THE CONTEXT OF BPD

According to the DSM-5, Borderline Personality Disorder is characterized by intense and turbulent moods and relationships, an unstable sense of self, and impulsive, self-destructive behaviors. Individuals with BPD tend to experience an anxiety marked by separation insecurity, which encompasses a fear of rejection as well as a fear of separation/abandonment. Separation insecurity is associated with fears related to dependency and loss of autonomy. If you experience separation insecurity, you may experience the fear of losing control, the fear of falling apart, and/or the fear of disappearing/not existing. 

Due to anxiety surrounding separation, individuals with BPD may also highly attuned to cues from others. You may be adept at noticing when another person has a subtly different expression, or you may notice subtle mood changes in others. Individuals with BPD are prone to making negative interpretations of these cues due in part to the fear of rejection/abandonment and the desire to prevent it at all costs. This sensitivity to cues from others can be frustrating, because you may find that you accurately identify a subtle change, but you're prone to misinterpreting the source of the change or the meaning of it. If you misinterpret the cues, you may invite defensiveness in other people if you make accusations based on your misinterpretations. Even if you don't misinterpret the cue, but you try to point out a subtle shift in a nonjudgmental way, you may still run the risk of being invalidated because many people are unaware of these shifts. Interactions like this can also occur in a therapeutic setting, and can lead to ruptures in the treatment relationship if the therapist is not self-aware. 

MY RESPONSIBILITY TO YOU

I want to know if I miss anything and I want to know if you're unsettled. Sometimes therapy involves working together to resolve conflicts in the therapeutic relationship, which allows for building trust and valuable interpersonal skills in real time. If you choose to work with me, I will commit to being as honest with myself as possible as well as I am always open to feedback and discussion if we have a miscommunication.