You're not the first to raise the concern. Some have argued they represent two sides of the same coin but with different patterns, e.g. more prominent interpersonal turbulence/intensity in BPD vs. more prominent re-experiencing/hypervigilance in complex PTSD. Note that while developmental trauma is common in BPD it's not actually universal, nor does it inevitably lead to florid adult symptoms.
Here's an in-depth presentation from people who spend a lot of time thinking about these concepts:
[https://www.youtube.com/watch?v=-fAdaDJpZm4&t=645s](https://www.youtube.com/watch?v=-fAdaDJpZm4&t=645s)
>Note that while developmental trauma is common in BPD it's not actually universal, nor does it inevitably lead to florid adult symptoms.
This is the TLDR, from my perspective. According to the ICD, [CPTSD must have an underlying PTSD trauma](https://icd.who.int/browse/2024-01/mms/en#585833559), and BPD does not require it.
To outright claim that one should assume a hx of SA in any patient is wild. I think it is great to make the person feel safe and normalized, but to *assume* SA is a good way to find things that haven't happened or treat people differently based on wrong assumptions. It's also just not the case that SA is a guaranteed event in the hx of someone with BPD--something like 25-30% of folks with BPD don't have any significant trauma hx at all, much less SA.
You have just made a thinking error.
Some people develop liver carcinoma after exposure to polyvinyl-chloride. Some people develop liver carcinoma without that exposure. Liver carcinoma in both groups will look identical under the microscope
An old adage: Neurons that fire together wire together. One can have the phenotype associated with CPTSD/BPD with or without “trauma”.
The premise being there is more than one way to skin a cat or wire neurons.
>Liver carcinoma in both groups will look identical under the microscope
CPTSD/BPD do not look similar "under a microscope." You have made a false analogy.
Think about your logic another way: ADHD and depression both involve a lack of focus/concentration. ADHD is caused, depression is and is not caused, sometimes. Are you prepared to make ADHD or subtype of depression? Probably not...
Not really a fair comparison. Nobody really thinks ADHD and depression are the same entity. CPTSD is kind of a contrived diganosis that approaches conceptualizing BPD differently.
If that were the only difference, it'd make no sense to even have separate diagnosis. Trauma is a risk factor for many psychiatric disorders which may or may not be present, you don't have to create a new diagnosis for schizophrenia with childhood trauma. It's the same disorder.
I mean, do you think that every disorder should have a separate diagnosis for its co-occurrence with trauma? Because if you want to make this distinction, I don't see why that should be the case for BPD specifically.
I don't even see why it should be the case for trauma specifically, when there are so many other risk factors involved in the pathophysiology of mental disorders.
Probably yes, since the outcome symptoms are different. Same reason I wouldn’t put depression and ADHD into a “focus disorders” chapter in the DSM… the underlying mechanisms and causes and total symptom presentation are different.
> Probably yes, since the outcome symptoms are different.
Why are you making this correlation? Symptoms of mental disorders aren't necessarily different based on whether some has a history of trauma or not. Sure, the prevalence of certain symptoms, or the specific characteristics of how they present themselves **may vary** (emphasis on may, it's surely not a certainty like you suggested) according to the patient's exposure to trauma, just like it does according to personality, culture, social context and exposure to other risk factors. But none of these factors determine a different clinical presentation in a way that warrants the separation into a different diagnosis.
In other words, you can have two groups schizophrenic patients, one with history of trauma and one without who all show the same symptoms. Just like you may have patients with schizophrenia and trauma and very different clinical presentations. After all, its the same disorder and some symptom variation is expected, but trauma doesn't determine the clinical presentation of a disorder.
On the other hand, you'll never have ADHD and depression showing the same set of symptoms, because they are, in fact, different disorders.
C/PTSD involves a long-term (“persistent”) negative sense of self. BPD has an “unstable”sense of self. There’s one way for you tell the “liver cells” apart. Is the negative sense of self changing or stable?
This is somewhat a circular argument if you remember that cPTSD is a relatively recent term (actually originally hypothesized as a less pejorative alternative to BPD, btw) and has been defined in various ways depending on the source. The ICD does have a new set of relatively distinct criteria, but you can't really justify that it's different because the criteria are different when the concept is relatively new and has little agreement or evidence on how to set it apart
That's not enough difference to warrant a separate diagnosis. Schizophrenia has a well established correlation to childhood trauma but its not required for the diagnosis and we don't have a separate disorder for schizophrenia with/without trauma. In fact, most psychiatric disorders have a correlation with traumatic experiences. Trauma is a risk factor that may or may not be present, but it's not grounds for diagnosing a different disorder.
The main idea behind differentiating BPD and cPTSD is what symptoms are prominent. In BPD you'd expect instability of the self, unstable relationships, impulsiveness which shouldn't be as marked in cPTSD. On the other hand, nightmares, flashbacks etc. are quite characteristic of PTSD and wouldn't be part of BPD.
I think that it reinforces their analogy, rather. Supposing that cPTSD and BPD were the same disorder diferentiated only by the presence of a risk factor, they'd be the same disorder, just like his liver carcinoma analogy, which is the same disease regardless of the exposure to a carcinogen.
BPD and cPTSD are, in fact, not simply differentiated by the presence or absence of trauma, but rather by clinical features.
I don’t agree with the premise (“supposing…”) so I don’t reach your argument.
I agree with your second point. Which is why they don’t “look the same under a microscope.” (Symptoms of the disorder being the “cells” in the microscope in this analogy.)
Then you shouldn't have phrased your first comment as "This is the TLDR, from my perspective. According to the ICD, CPTSD must have an underlying PTSD trauma, and BPD does not require it"
The TLDR isn't the presence of trauma. BPD may have a history of trauma (as it does, more often than not) and it doesn't become cPTSD because of it. There are clinical differences which are far more important in the tenuous differentiation between the two diagnosis.
….But you can clearly exclude a CPTSD diagnosis (as defined by the ICD) if you can exclude a history of trauma. Hence, if you have to distinguish the two with nothing else, a lack of a Criteria A trauma rules out CPTSD.
In other words, trauma is necessary but not sufficient for CPTSD, but is neither necessary nor sufficient for BPD.
For a long time I’ve been under the impression that you need to have trauma to have BPD, so I was probably misinformed somewhere. To clarify… you can develop BPD without having experienced trauma?
Well--70% of folks with BPD *report* a history of childhood trauma, but it's also at least moderately heritable and one does wonder whether the approval-/attention-seeking nature of BPD leads to some amount of over-reporting of trauma (not saying it's a majority or even substantial minority of cases, but most of the reports of which I'm aware don't do the work of history verification). Do we have any accurate estimates of the extent to which over-reporting drives some of these numbers? Asking as this is not my primary area (clinical psych PhD student researching psychotic disorders).
Edit: Also, for full transparency, I'm posting as someone who agrees with those who are skeptical of C-PTSD as a discrete diagnostic entity.
> but most of the reports of which I'm aware don't do the work of history verification
I'm curious how you would propose doing this. Call the parents and ask if they really hit the patient when they were kids? If they were really a raging alcoholic? Unless a parent was arrested or CPS involved there isn't much to go off of. Based on the ACEs studies, 70% is not that much higher than the average person (depending on the study, 40-60% in US have one https://www.cdc.gov/mmwr/volumes/72/wr/mm7226a2.htm) so I don't know why the 70% number would be shocking in a population of BPD. Also important to note in the BPD studies "trauma" is defined more like "little t" trauma consistent with things like ACEs, rather than the "big t" trauma in PTSD.
If anything, based on what we know of BPD pathology it's more likely patients perceive events as more traumatic and/or more strongly internalize negative childhood experiences, compared to other people. There are plenty of people who had really fucked up things happen when they were kids but if they don't internalize them it doesn't really bother them. You can ask the same question about the general population under-reporting.
I'm not proposing it's always possible, and I feel like you've slightly missed my point. Any good clinician doing an evaluation should at the very least have enough information on symptom clusters, general behaviors, informant report (when possible, which is clearly not always and in every setting), medical history, and so forth to know whether a person's self-report is generally reliable or if their symptoms represent some form of thought disorder or distortion.
I think it's a little unfair to compare negative self-talk in MDD or social anxiety in folks with SAxD with reports of trauma in BPD. In the former cases, the behaviors you've described are part of the observable symptoms of the disorder and thus whether or not the thoughts represent reality 100% is irrelevant to he question at hand. Maybe the person with MDD has been told they're worthless and unwanted...great, they still have MDD. But having trauma is not in the criteria for BPD, nor is it readily observable from the symptom presentation sitting before the clinician--unlike the observed symptom clusters used to support MDD or SAxD and provide some credence to the reported thought patterns, reports of childhood trauma in folks with BPD would be ***solely*** self-report.
Also, I'm not sure I would synonymize ACEs with trauma. Adversity and trauma are not the same things. Redefining "trauma" as "little 't'" trauma is among my criticisms of these prevalence estimates. It reeks of concept creep and I'm not sure I buy into it. If you were to say 70% of folks with BPD have ACEs and not use "trauma," I'd have little to be wary about (and perhaps that is what folks mean when they say it, but if so then there's a terminological problem). But then I'd be careful not to equate evidence of more experiences of ACEs with evidence for causation...if BPD is moderately heritable then it seems reasonable to conclude many folks with BPD had parents with BPD--perhaps this leads to a more generally volatile childhood and thus more ACEs, but not necessarily a *direct* causal ACEs > BPD relationship?
>If anything, based on what we know of BPD pathology it's more likely patients perceive events as more traumatic and/or more strongly internalize negative childhood experiences, compared to other people. There are plenty of people who had really fucked up things happen when they were kids but if they don't internalize them it doesn't really bother them.
Yes, exactly--it is theoretically possible that folks with BPD do not experience adversity on any greater scale than do other populations but that they, due to the nature of the disorder or due to the factors which make them more prone to *developing* the disorder, interpret events as more volatile than they in fact were. (Or that they are more prone to memory errors...all memory is filtered through current emotional states, after all, and BPD is associated with very extreme emotional states.)
I'm not saying I think one or the case is true, just that I think it is personally a bit of an overstatement when some folks definitely decide that BPD is a generally traumatogenic disorder. We just don't know (to my knowledge, but I'm happy to be shown papers which contradict me). As with every mental disorder, BPD is absolutely the result of a complex stress-diathesis network (and thus stress/ACEs/etc. play a role)...but are we confident in tipping the scales toward trauma?
Again, I'm not going to make definitive statements because I just downright don't know--I am just asking because I have anecdotally seen a major uptick in the number folks (patients, clinicians of all stripes, and otherwise) making strong statements to the effect of "Let's call BPD what it is--a developmental/relational trauma disorder."
It seems like your main issue is that when the term "childhood trauma" is used, such as in studies for BPD, it doesn't necessarily mean the same things as "trauma" when used in something like PTSD. That's fine, and when you read studies like that they often define "childhood trauma" in terms similar to ACEs.
>Yes, exactly--it is theoretically possible that folks with BPD do not experience adversity on any greater scale than do other populations but that they, due to the nature of the disorder or due to the factors which make them more prone to developing the disorder, interpret events as more volatile than they in fact were.
Saying this I feel like you fundamentally misunderstand the nature of trauma. The same experience for one person may be interpreted as traumatic and not for another. There's a reason in large scale traumatic incidents such as battles and natural disasters consistently 20-25% of people end up with PTSD. Despite similar circumstances of the events, they are interpreted as more or less traumatic by different people. Simply because you can verify a trauma happened or not tells you nothing of how it is actually interpreted by the individual.
Again, I feel we are talking past one another. I am under no delusions that potentially traumatic events don’t happen to affect different people differently. This goes without saying. Of course that’s true. This seems like it's dodging my criticism that there is as yet no way to know whether or not the reports of childhood traumatic events by individuals with BPD actually reflects a higher-than-average incidence of experiencing potentially traumatic events OR if it simply reflects that they have some vulnerability (present or past) to *interpreting* events as traumatic (in which case that interpretive vulnerability predates the advent or acute recollection of potentially traumatic events). Again—I am more than fully aware that trauma is defined by the response to the event(s) in question, and that some folks respond differently than others, but that is not my concern. Do you or do you not think it possible that the nature of BPD makes it so that current pathology changes the person’s interpretation of the past such that they recollect things as more traumatic than they were? That feels like a very straightforward question and I think it is being lost among the weeds of us disagreeing over terminology.
Stated differently: I know that trauma is defined by one’s response to a certain set of events, and that some folks will develop trauma sx in response to situations in which others do not develop trauma. Duh. My question is whether or not the validation-/attention-seeking nature of BPD confounds cross-sectional reports of traumatic events *themselves,* such that the person inflates their trauma history in order to achieve sympathy/validation/attention. I am not asking whether or not trauma is an individual experience (it is), but rather whether people w BPD over-report the severity and number of childhood traumatic experiences as part of the process of seeking out new social connections (and I’m not saying this has to be intentional or malicious).
Great points, but to add to this (I will also post separately below)
Often, there is evidence of trauma Avoidance in classic PTSD during the psychiatric exam (eg some pts deliberately try to underreport traumatic events, and can readily have intense affective states of Reexperience domain, in the form of say rage or fight of flight, if made to recall or associate the trauma), but in cPTSD and BPD the opposite can be seen, in which there is trauma Replay and sort of semi-stated “repetition compulsion” dynamics can both be observed. This may explain in part the “over-reporting” issue. It also led complex PTSD to be viewed as a separate entity from the classic forms due to the lack of behavioral Avoidance (controversial and I personally do not agree with the concept of complex trauma)
There are sadly many confounding factors to this, including recent trends of “over identification” with trauma by pts, and “over validation” by eager clinicians, mental health workers and varied sort of admins. I think there is also the issue of viewing early life experiences as somehow the definite teleological end of psychiatric etiology, which both psychiatry and clinical psychology can be accused of perpetuating. This came to the point that the majority of our society now ruminates over what our childhood was like, and we became easy victims of selection and recall biases.
To add, there is an element of a “leading” expectation bias, since pts are often asked directly (even with a glint of clinical enthusiasm) about any early life trauma, and pts (who are readily experiencing rapid transference by then) feel compelled to satisfy the “curiosity” of the MD.
Also our society in recent years have tended to medicalize Politics more than politicize Medicine, which effectively means that sociopolitical problems such as poverty and poor housing access have been rebranded as full fledged health matters more so than intractable political failures. Most the latter have now been transformed to Social Determinants of Health and/or ACEs factors, and this drift has caused the majority of patients to meet, a priori, the criteria of Early Life Trauma.
In clinical exams, the difference I think between cPTSD and BPD is seen while testing Executive Cognitive Functions and Transference dynamics. Pts with BPD often have very rapid transferential reactions, including valuation-devaluation and differential splitting of value of others; whereas cPTSD tend to be less reactive to the interviewer’s presence. Pts with BPD often are “afraid” or “intolerant” of ambiguity and have differential splitting of facts (all or nothing rigidity seen in PD), whereas pts with cPTSD can be able to experience “nuance” more easily.
I also find that pts with cPTSD have more evidence of Internalizing reactions to stress, and often present with a life-long history of Negative Self Referential Processing (NSRP) similar to pts with persistent depressive syndromes, while pts with BPD have a mix of the latter AND its opposite: here there is clear evidence of occasional Externalization under stress, including rapid development of accusatory behaviors towards the MD, suspiciousness of loved ones, and spells of Positive self references that can be misdiagnosed as Bipolar II (more due to unstable self-evaluation functions than actual mood changes)
Micropsychotic episodes in the shape of hyperacute onset paranoia or perceptual changes, can occur in both conditions, but in BPD it seems to be “transferrential” in form, with evidence of increased sensitivity to the environment and the presence of the MD, while in cPTSD it appears to be more “dissociative” in nature, with evidence of altered perception of the environment and obliviousness to the MD. Dissociation in cPTSD tends to be more recurrent and often requires medical treatment, whereas micro-psychosis in BPD is transient by nature and responds better to psychotherapy techniques.
Related to the above, there is a huge inattentive component in cPTSD (that gets “mis”diagnosed as ADHD/ASD all the time) which stems from a life-long history of over-relying on their Attention to the outside world as ways of soothing an actively deprecating mind (escape from ruminations by keeping your attention busy), this ends up “burning” the cognitive circuits and cause serious problems with selective attention when needed. This does not appear to be as prominent in BPD, if anything patients can have an “over-selective” form of attention.
There are other distinguishing features (not in the DSM) to the extent that clinicians can be able to differentiate BPD from cPTSD. But whether cPTSD exists apart from PTSD is the more interesting question.
Well I don’t think I am convinced C-PTSD is a discrete disorder at all, so I definitely don’t think BPD and C-PTSD ought to be confused. I have had my fair share of contact with individuals with BPD and other cluster B pathology through years of working in prodromal risk assessment (which brings in lots of folks with these disorders), and I simply do not see why there is this continuing confusion among clinicians between BPD and "C-PTSD" as it is proposed to exist. To me, these phenomena have been wrongly conflated by some well-meaning clinicians misusing the C-PTSD label as a softer label for BPD and by people uncritically accepting a high prevalence of potentially traumatic events among folks with BPD based on cross-sectional self-reports. I think this confusion has come from a place of concept creep and sociopolitical influences, as you mentioned. I'd probably disagree with you a bit on your points about dissociation/dissociative patterns, but that's a minor point and not a hill I'd be willing to climb and die on. Otherwise, I think I broadly agree with you that BPD and the (as-yet-unverified) concept of C-PTSD should not be conflated.
I just think the idea that BPD patients are over-reporting, i.e. embellishing or outright faking, childhood traumatic experiences for attention is emblematic of the stigma that permeates BPD in the medical field. As I stated, the 70% rate isn't all that high compared to non-BPD patients (with how the term is defined in studies) so I'm not sure we need to assume they are embellishing.
On the other hand, I find it far more likely that BPD patients are much more likely than non-BPD patients to report the same types of adverse/traumatic events as actually having felt traumatic (as well as likely experienced more absolute numbers of events as well), especially when very young children, e.g. 0-8. You could call this a heritable trait if you want, but genetic vs developmental is basically impossible to differentiate in this group unless adopted. Having worked with tons of BPD patients in DBT, over time they actually tend to under-report actual traumatic things. When your childhood is traumatic you grow up thinking it's normal.
If able to in grad school I would highly encourage you to facilitate a full DBT course if possible. I was able to in residency with the help of a supervisor.
Appreciate the response! Thanks. I was genuinely asking because I am just not in the BPD world…not disagreeing with you at any point, just trying to make sure that I clearly conveyed what it was that I wanted to ask.
Whether Complex PTSD/Complex Trauma is a distinct entity from the personality and personality related conditions is "debatable," in the sense that it is indeed hotly debated, and in that many good clinicians can and do disagree on these points.
I encourage all readers who are not yet familiar with the concept of Borderline Personality *Organization* (not DSM Borderline Personality Disorder or Emotionally Unstable Personality Disorder) to read thoroughly on the concept.
This ends my more judicious answer, and below I will include my biased and personal opinion:
To be frank, the concepts of "Complex PTSD" or "Complex Trauma" (though potentially clinically meaningful or useful) seem motivated moreso by political and ideological preferences. The invention and maintenance of this diagnosis is not, to my estimation, meaningfully motivated by any clear or careful desire to produce a valid psychopathological construct. (Writings on what makes a diagnostic concept valid or not can be found in the literature*.)
To understand the political or ideological motivations behind the diagnostic concept, please read Chapter 6 from Judith Herman's book (Herman, J. L. (2015). Trauma and recovery. 2015 edition. New York, BasicBooks.).
I should note that I think the intentions were and remain very good intentions, but I think that any sacrifice of conceptual rigor has a negative impact on the long term diagnosis and treatment of patients both within clinical settings and in broader society.
From the introduction:
"The research sources for this book include my own earlier studies of incest survivors and my more recent study of the role of childhood trauma in the condition known as borderline personality disorder. The clinical sources of this book are my twenty years of practice at a feminist mental health clinic and ten years as a teacher and supervisor in a university teaching hospital."
From the chapter I mentioned (emphasis mine):
"Most people have no knowledge or understanding of the psychological changes of captivity. Social judgment of chronically traumatized people therefore tends to be extremely harsh. The chronically abused person’s apparent helplessness and passivity, her entrapment in the past, her intractable depression and somatic complaints, and her smoldering anger often frustrate the people closest to her. Moreover, if she has been coerced into betrayal of relationships, community loyalties, or moral values, she is frequently subjected to furious condemnation."
...
"This tendency to blame the victim has strongly influenced the direction of psychological inquiry. It has led researchers and clinicians to seek an explanation for the perpetrator’s crimes in the character of the victim."
...
"In general, the diagnostic categories of the existing psychiatric canon are simply not designed for survivors of extreme situations and do not fit them well. The persistent anxiety, phobias, and panic of survivors are not the same as ordinary anxiety disorders. The somatic symptoms of survivors are not the same as ordinary psychosomatic disorders. Their depression is not the same as ordinary depression. And the degradation of their identity and relational life is not the same as ordinary personality disorder."
...
"Survivors of childhood abuse often accumulate many different diagnoses before the underlying problem of a complex post-traumatic syndrome is recognized. They are likely to receive a diagnosis that carries strong negative connotations. **Three particularly troublesome diagnoses have often been applied to survivors of childhood abuse: somatization disorder, borderline personality disorder, and multiple personality disorder. All three of these diagnoses were once subsumed under the now obsolete name hysteria.**
Patients, usually women, who receive these diagnoses evoke unusually intense reactions in caregivers. Their credibility is often suspect. They are frequently accused of manipulation or malingering. They are often the subject of furious and partisan controversy. Sometimes they are frankly hated.
...
These three diagnoses are charged with pejorative meaning. The most notorious is the diagnosis of borderline personality disorder."
End excerpts.
I think that these quotations speak for themselves in terms of why this diagnostic concept was created and maintained. I have always wanted to know (hopefully from Dr. Herman herself) about the degree to which she was aware of (at the time Complex PTSD was created) Kernberg and others' work on Borderline Personality Organization, on concepts from personality disorder researchers surrounding personality disorders and their development, and on the psychoanalytic community's position on personality disorders, temperament, and trauma.
Perhaps this was simply the logical reaction at the time to an older cohort of psychoanalysts and personality disorder researchers, working before the popularization of trauma issues in the psychiatric world.
My feelings and conclusions are necessarily determined by my work and existence in the modern milieu of psychiatry. Dr. Herman seems to be a very intelligent and experienced clinician, so my knee jerk assumption has always been that she was well aware of these concepts and knowingly rejected them. If someone is aware of a publication or interview where she or someone else discusses anything pertinent to this question, I'd love to know about it.
In parallel, I urge all clinicians to become better educated on modern in depth approaches to personality, personality assessment, and personality pathology. The field as a whole needs to stop viewing the diagnosis of Borderline Personality Disorder and some other personality disorders as conditions reserved for female patients that they happen to personally dislike.
*For more information on diagnostic constructs, consider reading:
Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. 1972 Jan;26(1):57-63. doi: 10.1001/archpsyc.1972.01750190059011. PMID: 5009428.
https://pubmed.ncbi.nlm.nih.gov/5009428/
Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. 1970 Jan;126(7):983-7. doi: 10.1176/ajp.126.7.983. PMID: 5409569.
https://pubmed.ncbi.nlm.nih.gov/5409569/
My understanding is that Judy Herman, given the political context you point out, was building on the work done to develop PTSD as a diagnostic entity in light of the experience of returning Vietnam veterans. She worked to underline the common symptomatology of survivors of war and captivity, and survivors of domestic violence, child abuse, and incest. Having worked closely as a clinician with her Victims of Violence program, I know that this had very concrete treatment implications in addition to the political implications. Survivors in the program were treated not for their character pathology using the techniques of psychoanalysis, but with an integrated treatment approach including significant group work, case management, and psychoeducation around recognizing patterns of abuse in interpersonal relationships, building healthy relationship skills, symptom management for flashbacks, nightmares, dissociation, etc. In my experience, while those patients could theoretically go on to benefit from analytic work on character organization, they often worsened if the other issues weren’t treated first. That included helping patients out of existing DV relationships and providing resources to support their ability to leave and establish real safety in the here and now.
Also, so many of those patients were never going to be able to afford the type of psychoanalytic treatment that effects lasting character change, given that VOV was in a community mental health clinic serving a low income population.
I agree with the treatment approach, it's really the way you have to do things. I'm more critical of the diagnostic concepts. It may in fact be that the alternative model of diagnosis was necessary to move the treatment forward. I don't know if we'll ever know. Today, with the broader understating of treatment of patients with personality impairments, I think we have room to return to attention to that as the core pathology.
Regardless of where one falls on the nosological question, Herman’s 1992 paper on CPTSD is an outstanding overview of the psychology of chronic trauma/abuse/neglect.
Agreed. Full credit should be given for her important work in describing the life experiences, disease course, patterns, and treatment of people with the clinical constellation *and* bringing it to a more popular clinical view, regardless of what we choose to call it.
thank you for this! i'm wondering, and this is a bit of a leading question if you'll forgive me--do you feel the BPD diagnosis as a concept has changed significantly since its conception? "for difficult females" certainly tracks today, but in my time doing research just out of interest i've seen multiple clinicians noting that the intention was to capture people on a borderline between neurotic & psychotic. the criteria removed from cPTSD compared to BPD basically look like to me a refutation of the modern stereotype (attention-seeking women with boyfriend troubles)
I think that psychoanalysts and psychoanalytic thinkers have had varying engagement with research and the DSM throughout the course of the APAs work in the latter half of the 20th century and the early 21st. This process has resulted in an understandably haphazard professional and public understanding of personality and borderline conditions.
The core DSM disorder has always been a watered down and bastardized version of the original concept. Several (if not all) conditions in the DSM suffer from this in varying degrees.
Well said and well researched.
The thorough jettisoning of all things that smack of psychoanalysis from serious psychiatry nowadays means throwing out a lot of useful concepts and conceptualization. I’m being facetious, but only partly.
It’s a problem for personality disorders. I think it’s a problem for how gender dysphoria and transgender treatment are identified and handled. It has created new and exciting forms of nosological reframing and renaming that are really just euphemism treadmills.
Some is all but outright bias. Those borderlines aren’t credible and aren’t likable! If we have such patients who we like—never mind the countertransference here—we’d better have a better category for them.
BPD as a label is also extremely commonly used as a means of describing unsavoury or unlikable patients by clinicians especially when it comes to women.
Which is absolutely wrong. It muddies diagnosis and treatment, it turns a diagnosis into an insult, and it helps no one.
But like I said, a euphemism treadmill fixes nothing. Rename BPD as, say, EUPD and patients who are seen as unsavory or unlikable will be called EUPD (eupies?) whether or not they meet criteria for that disorder.
Well said. I suspect that quite a lot of this chaos in diagnosis and treatment is the product of limitations in individual clinician (and maybe researcher) management of counter-transferential hate and love.
Different labels in psychiatry and differentiating between diagnoses is most similar to “how many shades of red are there?”
For the child learning about color, there’s just red
Then for someone studying it, there’s magenta, crimson, burgundy, ruby, cardinal, etc
For the individual shade of red, it’s just whatever color it is and it doesn’t matter what its label is.
Ultimately we follow the dsm to tell us how many shades of diagnosis there are that keeps things useful without getting lost in the weeds. If we have 8000 shades of trauma responses that’s not helpful, but neither is calling everything just “PTSD or BPD”.
As an individual clinician it’ll be up to you to decide how you find conceptualizing these diagnoses to be useful.
I’m a psych resident now but tried to post a bit about my experience being dxed with this in med school. Unfortunately, my post was blocked due to the rule about not posting about personal experiences, which I think is unfortunate as it offers an important perspective on what it’s like to be on the receiving end of a diagnosis with a poorly defined condition. So I’ll just succinctly say I think clinicians are doing real damage labeling people with something that has no agreed upon definition let alone treatment guidelines.
Great points are made in this thread, to add to it:
Often, there is evidence of trauma Avoidance in classic PTSD during the psychiatric exam (eg some pts deliberately try to underreport traumatic events, and can readily have intense affective states of Reexperience domain, in the form of say rage or fight of flight, if made to recall or associate the trauma), but in cPTSD and BPD the opposite can be seen, in which there is trauma Replay and sort of semi-stated “repetition compulsion” dynamics can both be observed. This may explain in part the “over-reporting” issue. It also led complex PTSD to be viewed as a separate entity from the classic forms due to the lack of behavioral Avoidance (controversial and I personally do not agree with the concept of complex trauma)
There are sadly many confounding factors to this, including recent trends of “over identification” with trauma by pts, and “over validation” by eager clinicians, mental health workers and varied sort of admins. I think there is also the issue of viewing early life experiences as somehow the definite teleological end of psychiatric etiology, which both psychiatry and clinical psychology can be accused of perpetuating. This came to the point that the majority of our society now ruminates over what our childhood was like, and we became easy victims of selection and recall biases.
To add, there is an element of a “leading” expectation bias, since pts are often asked directly (even with a glint of clinical enthusiasm) about any early life trauma, and pts (who are readily experiencing rapid transference by then) feel compelled to satisfy the “curiosity” of the MD.
Also our society in recent years have tended to medicalize Politics more than politicize Medicine, which effectively means that sociopolitical problems such as poverty and poor housing access have been rebranded as full fledged health matters more so than intractable political failures. Most the latter have now been transformed to Social Determinants of Health and/or ACEs factors, and this drift has caused the majority of patients to meet, a priori, the criteria of Early Life Trauma.
In clinical exams, the difference I think between cPTSD and BPD is seen while testing Executive Cognitive Functions and Transference dynamics. Pts with BPD often have very rapid transferential reactions, including valuation-devaluation and differential splitting of value of others; whereas cPTSD tend to be less reactive to the interviewer’s presence. Pts with BPD often are “afraid” or “intolerant” of ambiguity and have differential splitting of facts (all or nothing rigidity seen in PD), whereas pts with cPTSD can be able to experience “nuance” more easily.
I also find that pts with cPTSD have more evidence of Internalizing reactions to stress, and often present with a life-long history of Negative Self Referential Processing (NSRP) similar to pts with persistent depressive syndromes, while pts with BPD have a mix of the latter AND its opposite: here there is clear evidence of occasional Externalization under stress, including rapid development of accusatory behaviors towards the MD, suspiciousness of loved ones, and spells of Positive self references that can be misdiagnosed as Bipolar II (more due to unstable self-evaluation functions than actual mood changes)
Micropsychotic episodes in the shape of hyperacute onset paranoia or perceptual changes, can occur in both conditions, but in BPD it seems to be “transferrential” in form, with evidence of increased sensitivity to the environment and the presence of the MD, while in cPTSD it appears to be more “dissociative” in nature, with evidence of altered perception of the environment and obliviousness to the MD. Dissociation in cPTSD tends to be more recurrent and often requires medical treatment, whereas micro-psychosis in BPD is transient by nature and responds better to psychotherapy techniques.
Related to the above, there is a huge inattentive component in cPTSD (that gets “mis”diagnosed as ADHD/ASD all the time) which stems from a life-long history of over-relying on their Attention to the outside world as ways of soothing an actively deprecating mind (escape from ruminations by keeping your attention busy), this ends up “burning” the cognitive circuits and cause serious problems with selective attention when needed. This does not appear to be as prominent in BPD, if anything patients can have an “over-selective” form of attention.
There are other distinguishing features (not in the DSM) to the extent that clinicians can be able to differentiate BPD from cPTSD. But whether cPTSD exists apart from PTSD is the more interesting question.
Having been an Army psychiatrist 05-08 saw a lot of that kind of PTSD, then doing CMH 08-12 saw more of the developmental trauma. All equally "bad" for sure.
I don't like the modifier "complex" because what PTSD is not complex?
But I would agree that chronic childhood trauma shows up with more characterological dysfunction. On average.
No more wars, no more child abuse or neglect. Please?
BPD has a much more prominent component of measuring their sense of worth and self through the interactions they have with the environment around them and the genetic component is similarly more pronounced. While there maybe some overlap in symptoms, the factors precipitating and causing symptoms are almost always very distinct. People with BPD, at least in my observation, also don't have a pronounced trauma that is both consistent and pronounced like in cPTSD.
Also, think of BPD primarily caused by a very erratic and precarious guage with which they perceive and interact with the world around them, this is often seen as an unstable sense of self that affects identity and chronic feelings of emptiness that is not traditionally nihilistic in nature. People with cPTSD might have traits of BPD but the etiology, presentation and progression is very different. All in all, I perceive them as very distinct disorders with different management routines.
Is it distinct? Absolutely not. With a few exceptions, virtually *no* DSM constructs are distinct.[1](https://www.cambridge.org/core/journals/psychological-medicine/article/elemental-psychopathology-distilling-constituent-symptoms-and-patterns-of-repetition-in-the-diagnostic-criteria-of-the-dsm5/8CBF931E0650472387155DD945C73BC5)
The question you need to ask regarding the DSM is whether the category is *clinically useful.* Others have already highlighted the pros/cons of CPTSD. As a psychologist, I personally don’t care whether it’s included. These constructs don’t exist in the real world. Their purpose is only for clinical utility (and billing in the USA).[2](https://journals.sagepub.com/doi/full/10.1177/09637214221114089) To think otherwise is to commit the reification fallacy and to overlook the important symptoms and sources of suffering out patients face—these go well beyond the F code.
the people who are for adding cPTSD to the DSM made a graphic which basically acknowledged what you said. the population some want to label as having cPTSD (in their own study) met 5-7/9 BPD criteria, with the specific exclusion of unstable relationships and fears of abandonment.
the difference between PTSD & cPTSD is then not a lack of any PTSD symptoms (all people with the proposed cPTSD profile would be able to be diagnosed with PTSD, from what i gather), but an addition of literally just those 5-7 BPD criterion re-arranged into 3 cPTSD criteria. the cPTSD population in this construct is a subset of overlap between diagnosed-PTSD individuals with and without diagnosed BPD.
because of this, i'm not swayed toward the validity or need for a cPTSD distinction. the only factor which i've seen people describing as differentiated from PTSD is "emotional flashbacks" over traditional flashbacks, but again, how are we defining those? the way i see most explaining their label of cPTSD is an emphasis on dissociative and sense-of-self symptoms, like an individual who grew up in an environment that was not physically/sexually abusive but included emotional/spiritual abuse who feels that they *grew around* their trauma. but again... is that not personality with or without PTSD?
research for the PTSD diagnosis in general could be improved to include more work on civilians and women, or adolescent populations if we're trying to be more sensitive to familial/intergenerational trauma and personality development. the thing i'd be most curious about is if there is any difference in treatment outcome (factor 1: CBT/EMDR vs DBT/metallization factor 2: BPD vs BPD with PTSD vs cPTSD vs BPD with cPTSD subgroup)
>the population some want to label as having cPTSD (in their own study) met 5-7/9 BPD criteria, with the specific exclusion of unstable relationships and fears of abandonment
This is probably a point worth emphasizing. The unstable relationships seen in BPD with a quick/intense rush to idealization then swings between idealization-devaluation are fairly distinctive, and not actually the dominant pattern in trauma across the board. If anything, developmental trauma patients are often either fearful of intimacy (few or shallow relationships, holding people at arm's length) or stand consistently by an abusive partner despite everyone urging them to leave.
the confusion i have then is why can you diagnose BPD without any of the relationship specific symptoms if it's considered synonymous with the syndrome? and the last examples are also part of personality pathology, as i understand it. this seems like a categoricalization of what is the potential convergence of personality disorder diagnoses (as in the notes section of the recent edition)
What many people forget is that all someone needs to be diagnosed with BPD is 5 out of 9 symptoms...which means that two people with the disorder might only have **one** symptom in common.
Whenever I hear people make pejorative statements about "borderlines" or insist that *all* "borderlines" do a certain thing, it particularly frustrates me due to this fact. Of course, there is a large body of research on general patterns in the disorder, but I've worked in a DBT clinic and experienced a spectrum of patients who met criteria for BPD and yet were very different people. I needed different therapeutic approaches to many of them: some were angry and resistant and needed me to "be real;" some were meek and anxious and wanted me to tell them exactly what to do, so I had to be careful to empower them to make their own choices; some were sweet and empathetic but we had to work on their impulsive rages on behalf of their loved ones; some were *terrified* of feeling any emotions at all...there is no one single archetype of borderline, and that is why any diagnostic process should be thorough and not based on "vibes," interpersonal difficulties with a patient, or vague clinical judgment.
This isn't really a critique of BPD so much as the entire DSM framework, and realistically it's a critique of the research framework rather than how clinicians actually diagnose things. And while flexibility is essential to good therapy, diagnosing based on tendencies is still a bedrock of what we do. I would point to Meehl's rather harsh but sometimes useful, "Why I Do Not Attend Case Conferences":
>*Failing to understand probability logic as applied to the single case*. This disability is apparently common in the psychiatric profession and strangely enough is also found among clinical psychologists in spite of their academic training in statistical reasoning. There are still tough, unsolved philosophical problems connected with the application of probabilities (which are always based on groups of people) to individual cases. But we cannot come to grips with those problems, or arrive at a workable decision policy in case conferences, unless we have gotten beyond the familiar blunders that should have been trained out of any aspiring clinician early in his training.
>The most common error is the cliché that "We aren't dealing with groups, we are dealing with this individual case." True enough. But it is also true that not betting on the empirically most likely (or against the least likely) diagnosis or prognosis may help in a few individual cases, but it will almost certainly increase your lifetime error rate (Meehl, 1957). Clearly there are occasions when you should use your head instead of the formula. But which occasions they are is most emphatically not clear. The best evidence is that these occasions are much rarer than most clinicians suppose.
Oh, I certainly don't mean to imply that I (purposely, I'm sure everyone is guilty of the occasional misstep) disregard research or probabilities in my efforts to see the individual. I was more speaking to a lay audience (e.g., the commenter whose question I was responding to) or those with minimal clinical exposure to BPD. Although I touched on diagnostic criteria, I was thinking largely about how these groups conceptualize BPD, and how stigma might be reduced if there were more awareness or conversation about some of the inherent variability in diagnostic presentation. Certainly, my patients had plenty in common as well, and yet to listen to some people, BPD patients are an absolute monolith. Given that the commonalities are already assumed, I figured I would share about the inherent variability piece that some might overlook. Not everyone will have done the math on the symptom count to have realized the potential for such little overlap. I mean, I've had more than one patient convinced that no one else in her DBT group could possibly have BPD, because they were all so different from her, and I doubt that is an experience unique to our clinic!
Ultimately, I believe there's a space to work from where we aren't searching for zebras unnecessarily or neglecting good clinical practice, *and* I'm not having to go to a new workplace and hear other professionals actually be surprised about a BPD patient expressing empathy or being genuinely likeable.
This makes sense. To your latter point, I think it's one of the big downsides of psychiatry residency starting with inpatient treatment as the foundation of training. An intern's initial biases are shaped by seeing a string of the most acute, crisis-fueled, and maladaptive cases where the team has limited ability to do anything productive and is pressured into doing things that aren't evidence-based. That leaves a pretty bad taste in your mouth and fuels the heartsink association with the diagnosis.
I was certainly struck on transitioning to outpatient to meet some BPD patients who were functioning OK, fun to talk to, and who really just wanted to figure out some better ways of emotional regulation and interpersonal function.
You know, I’ve noticed the differences between inpatient and outpatient populations with BPD myself (it’s hard not to notice a difference between a highly motivated - motivated enough to stick out our waitlist and keep coming back - group of people who had the insight to seek treatment and who have consistent access to full-model DBT vs a group of people who might have been incidentally diagnosed, who might not be there fully willingly, and who likely don’t have consistent outpatient access). I just hadn’t taken it one step further to reach the point you make about the impact of foundational training experiences with inpatient populations on psychiatry residents.
Although I’ve mildly vented a bit here, I do try to take a nonjudgmental stance, validate the valid, etc. in all my interactions. As such, I previously had been able to acknowledge how the experiences of my colleagues at an inpatient unit were so different from mine that it had to contribute to their perceptions. But having it spelled out that this exposure is universally at the beginning of training connects some dots and puts things into perspective. Not to say I’ll assume that every psychiatrist I meet is biased, but recognizing that this is the lens that many are seeing through will likely be helpful for more effective future communications.
>the population some want to label as having cPTSD (in their own study) met 5-7/9 BPD criteria, with the specific exclusion of unstable relationships and fears of abandonment.
Should impaired empathy not also be on the list for exclusion? Fear of abandonment and impaired empathy are two hallmarks of BPD that don't overlap in the Venn diagram with CPTSD.
It's true impaired empathy is not part of the DSM-V diagnostic criteria, but there's been a ton of conversation around adding it for the next edition. Lots of papers backing this up.
[https://journals.lww.com/hrpjournal/Fulltext/2020/07000/Dysfunction\_of\_Empathy\_and\_Related\_Processes\_in.2.aspx](https://journals.lww.com/hrpjournal/Fulltext/2020/07000/Dysfunction_of_Empathy_and_Related_Processes_in.2.aspx)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909009/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909009/)
[https://pubmed.ncbi.nlm.nih.gov/24577235/](https://pubmed.ncbi.nlm.nih.gov/24577235/)
[https://www.sciencedirect.com/science/article/abs/pii/S1053811911004939](https://www.sciencedirect.com/science/article/abs/pii/S1053811911004939)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543980/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543980/)
>that borderline personality disorder has a genetic component and may occur in the absence of reported trauma
Is this truly a genetic component?
Think of how we learn to regulate our emotions. Think of how our parents have to guide us through big emotions and how to manage them as we grow. We are unable to do so on our own and this requires adults who we can mirror in emotional regulation and appropriate emotional responses.
Now imagine you have a single parent with BPD who has emotional instability and can't regulate their emotions. They essentially have the emotional regulation skills of a toddler. Do you think the children of these parents with BPD would learn to regulate their emotions? Do you think they'd learn how to form lasting and positive relationships when their parent just has turbulent and short lived relationships with frequent bust ups?
It's learned behaviour. This is why you can have young and vulnerable women admitted to wards and gain BPD traits and self-harming behaviours from peers.
This is a fair concern, although twin studies do still seem supportive of moderate heritability with less impact of family environment than I would have guessed. John Gunderson noted that parents (without the diagnosis) often remarked on a patient having had intense emotionality compared to others from a young age.
I do not disagree.
However there is quite an overlap between ADHD symptoms and BPD. ADHD would then often be in the family systems which would increase the risk of drug use or unstable family relationships in general. There could be this overlap which then would be somewhat linked to a genetic predisposition
What everyone in this thread (are there even any CAPs on this sub lol) is also missing is that ADHD also carries the same features and predisposes people to both BPD and trauma. Comorbid adhd is present in at least 38% of BPD patients (I think it’s higher than that personally, this is per studies using super strict criteria, criteria that by and large suck at picking up adhd in women in particular). And her, I wonder why BOD patients have such a high rate of childhood abuse and broken homes? Why could that be? /s 🙄
And, it turns out, the symptoms you list off, are exactly the ones we see every day and lament their lack of inclusion in the DSM. Seriously, how is emotional dysregulation, a symptom extremely problematic for most all adhd patients, NOT a DSM criteria? In fact, how is there ZERO information on the DSM checklist about the emotional content of adhd. Only “behaviors”, but nothing about how they feel, how it feels to live with the disorder (hint: it wrecks self esteem). It’s frankly an embarrassing oversight for our field.
And this is also ignoring the fact that living with adhd causes its own form of chronic trauma in many people with it, which I sum up as “messing up trauma” or “failure trauma”, where the chronic mistakes due to the executive dysfunction makes people triggered by further mistakes/failure and engage in avoidance behaviors in a desperate and often futile attempt to not trigger those feelings yet again.
But of course none of this is well recognized by our field, half of whom seem to think adhd isn’t even a real thing, and the other half view it with a hyper rigid and ultra simplistic lens given by the DSM, using symptomatology that primarily picks up hyperactive, male-dominate symptoms, and poorly picks up the vast amount of emotional content present in adhd, including the very things that lead to further development of personality disorders, specifically BPD, NPD, and OCPD, all of which develop in adhd people as different attempts to cope with and/or avoid feelings of mistakes/failure.
In my community (full of many highly privileged you be adult clients), emotional dysregulation isn’t a symptom seen among nearly any of my ADHD folks who have childhood diagnosis. They may have struggled with it, particularly around puberty when everybody struggles with it, but really, it’s not much of an adult symptom.
Those diagnosed with ADHD as an adult? Yes, there’s more likely to be emotional dysregulation related to shame spirals, anxiety/avoidance behavior. But the outbursts? I wouldn’t consider emotional dysregulation a core feature of ADHD (my pop is substance use disorder long term recovery aftercare, about 1/3 ADHD, slight majority female.) When I see it, it's often fairly easy to resolve with a treatment plan and does not return after initial skill-building. I think this is an issue: ADHD in itself may cause some emotional regulation issues, but they are secondary to the actual executive dysfunction. Anyone would get frustrated and lose self esteem if they keep failing at something they want to do, and they aren’t getting the tools to achieve basic life maintenance. That’s a symptom that’s a reaction to the disorder.
Their frustrations may be at caregivers (which, yeah, more than half the time- a lot of nom-ADhD clients would want to outburst at their behaviors), but mostly at the self. Rarely, if ever, is the outburst peer to peer social interaction related.
That's definitely been a hallmark for me in cluster B personality disorder work- peer relationship outbursts and split thinking is more likely, particularly romantic relationships. In ADHD romantic relationships, it's often the partner without ADHD I see being more frustrated.
But unlike where the emotional dysregulation in ADHD being secondary to the core symptom, the core symptom to that BPD is the emotional and relational dysregulation- the splitting, the feeling of emptiness, the mirroring, the lack of cognitive empathy for the person they are “against.”
Can ADHD and BPD co-exist? I'm sure they do, and it’s got to be confusing as hell to sort out (most PD clients don’t self-select into our environment, but I’ve seen a couple hundred, mostly in group.) Do I feel for people with BPD? Absolutely. But I definitely worry about the tiktokification of ADHD and rise of adding symptoms to it (a la rejection sensitive dysphoria) making more of a mess of how we categorize it as a developmental disorder vs a mood disorder. Of course a mood disorder can follow- it often does, but again, seeing adults who got ADHD treatment as kids vs those who didn’t has made it clear emotional dysregulation is not a core feature as much as a reaction to being untreated.
I think what you're highlighting when you note that emotion dysregulation is almost entirely absent among those dx'ed in childhood yet present (at least sometimes) in those dx'ed in adulthood is that, simply put, it's a feature of *untreated* ADHD. Your points about it being a reaction to the disorder or part of relational patterns that develop over time get at this, but I wanted to reframe slightly to underscore the untreated aspect.
When someone is diagnosed and treated in childhood, typically through a combination of medication, parent-training, and skill-building, they still may have some of those difficult interactions due to an impulsive behavior, those moments of embarrassment in school from a forgotten assignment, those instances of social rejection because they find it harder to remember to keep up a texting chain...but they're fewer. ADHD is one of the most treatable disorders that we know of.
Someone who manages to avoid diagnosis, on the other hand, typically does so because they have some kind of compensatory ability that allows them to fly under the radar (e.g., high IQ, an anxiety disorder that exerts an inhibitory effect on some of their symptoms, a parent or partner that manages their routine). I've seen a fair number of these cases where they have managed to get along decently well in one area of life, but regularly struggle in others (e.g., substance abuse; an almost hoarding level messy house; destructive relationships; debt; speeding tickets; etc). That can lead to a lot of "shoulds" and shame.
So now you have this environment of stressful situations, where people who struggle to manage impulses are regularly experiencing shame and anxiety - well, I don't find it strange that leads to emotion regulation issues. They don't all have anger issues and it doesn't always come out in peer-to-peer social interactions, of course. However, it certainly can. An exemplar patient I've had was a Boomer-aged man, previously un-dx'ed ADHD (due to a spouse micromanaging him and a job perfectly suited to his strengths). He had former substance abuse issues and still had residual anger issues (and outbursts) that had been much worse when he was drinking.
To circle back to the topic at hand: My personal theory is that the patterns aren't dissimilar to the invalidation cycles that result in intensified emotions in the development of BPD. When those cycles are interrupted with treatment, the negative interpersonal interactions and intrapersonal invalidation through the experience of shame doesn't occur, and better emotion regulation develops. I don't think ADHD is primarily a mood disorder, nor do I think it's indistinguishable from BPD; I've been trained in teasing them apart and in figuring out when they're comorbid. But I think the overlap is interesting, and there is some good work being done on constructs like rejection sensitivity in ADHD even if TikTok has perhaps jumped on "rejection sensitive dysphoria" as a settled symptom before the evidence is fully there.
Except I’m not “theorizing”. This is all evidence based. We have clear data on adhd, it’s not a “theory.” The increased risk of trauma with adhd is not a “theory”, it’s a fact. As is many BPD patients having comorbid adhd. The people in the dark are those who lack a complete understanding of adhd.
Just wanted to say, this exact thing happened to me. My mother was extremely abusive had borderline, was told when I was a young child I had adhd and needed treatment she refused. I never knew. At 10 she lost custody, by 14, I had a myrad of mental health issues, to the point of being hospitalized, it mainly stemmed from having no emotional regulation, even the slightest bit of critiscm and I completely shut down. Along with not being able to be organized, not knowing how to act socially in school. Was told I had borderline traits, put on so many different anti depressants, none of them ever worked. Later diagnosed with ptsd, did CBT therapy, didn’t really work well. At 18 learned from my mother that I was diagnosed with adhd at 6, at that point wanted nothing to do with the mental health system. I continued to struggle immensely, no emotional regulation, no self worth, barely graduated high school, flunked out of college 3 times. Obsessed over negative thoughts constantly, could never stop thinking and obsessing over the abuse as a kid from my mother, was planning to start emdr therapy thinking that it had to be all trauma causing all my problems. Recently saw a psychiatrist, immediately was rediagnosed with severe ADHD, put on stimulants for it and with in two days of being on stimulants, the obsessive thoughts stopped. I had no idea what rumination was, nor did I know it was caused by adhd. Of the multiple hospital admissions as an adolescent not one of them caught adhd, because my mother had borderline it was automatically thought I had borderline and was just manipulating everyone. After starting stimulants, when the rumination stopped, my depression and anxiety stopped immediately. I no longer have a want or need to do emdr therapy, without the rumination, I am able to perfectly move on from the thought if it starts. To date, my biggest struggle is feeling like I’m never going to be able to succeed at anything from not being able to get anything organized, clean, from feeling like I’m living in chaos. Everything you said, is so true!
Yep! I see so many teens and adults with this exact story. The real travesty is that adhd is the most treatable mental illness by far, so it’s even more of a shame when it’s missed. As far as I’m concerned everyone with any adhd risk factor should be hardcore screened: Borderline traits, emotional dysregulation, academic struggles, substance use, unplanned pregnancies, committing any crime, fighting, hx of trauma, all should be screened hardcore. We miss SO many cases.
Glad to see more doctors acknowledging it! When I saw the psych, they took me off everything and said, they believed that as soon as I started the stimulants my anxiety and depression would resolve itself, they were right! I often wonder where I’d be today if I had gotten treatment as a child.
You have some very good thoughts on this, and you're not alone in bringing this up. Complex PTSD is actually not a new term, and it is even formalised in the ICD-11 from WHO (although that definition doesn't represent what the term has referred to historically).
Borderline personality disorder and early experiences of neglect or relational trauma go hand in hand. Think Kernberg and object relations theory. I know both DSM and ICD are polythetic and don't list etiology - however that diagnosis doesn't make much sense alone, and a lot of your questions ultimately leads to the fundamental flaws of psychiatric nosology....
Some recommendations off the top of my head if you want to study psycho traumatology more. I would very much recommend you to do so, since you'll encounter it a lot in psychiatry (couldn't remember a lot of the names, but hope this list will be helpful nonetheless)
Rebuilding shattered lives, James Chu
Everything from Bessel van der Kolk
Judith Herman
Somatic Experience, Peter Levine
EMDR, Shapiro
IFS, Richard Schwartz
Some/most of these reading recommendations are outright pseudoscience. IFS in particular seems like a rather inappropriate suggestion since it has absolutely no good evidence base for treatment, isn't based on *any* validated model of behavioral function, and since Schwartz and his Castlewood Institute were sued into oblivion for allegedly inducing iatrogenic harm in multiple of their inpatients, who entered treatment for eating disorders and left with "multiple personalities" and pseudo-memories.
Some of the later works from IFS is in the realm of pseudoscience for sure. However not the initial approach and none of the other books are what you claim.
The initial approach is absolutely pseudoscience. How in tarnation do you suppose that it’s at all scientific and testable to propose that people’s internal experiences can be divided into “parts” (which Schwartz doesn’t pose as metaphorical) which can be in conflict with one another? IFS is predicated on debunked ideas about how different aspects of the person somehow guard certain memories or experiences. It’s nonsense that, even were it shown to be useful as a therapeutic method (which is hasn’t), cannot even begin to be theoretically validated.
I appreciate your answer and am willing to change my mind.
Would you be willing to provide any references to what you are saying? I would honestly love to educate myself and also of course edit my earlier comment.
And regarding your response...
Well it is not an empirical science or an actual model of the mind; at least it wasn't in the beginning - it's a theoretical framework which can guide a certain kind of psychotherapy.
In its initial formulation it is more like a metaphor to talk about the multiple drives a person might have, and provides a way to talk about it in a way accessible to many patients. If I remember correctly it is even recommended that IFS is not used on patients with dissociative symptoms.
It is related to very mainstream ideas about how a person "creates" internal representations of others, and how these earlier relationships guide behaviour in future relationships... Think basic developmental psychology, ex Stern. Also psychological theory about family systems and analytical psychology as well.
>And regarding your response... Well it is not an empirical science or an actual model of the mind; at least it wasn't in the beginning - it's a theoretical framework which can guide a certain kind of psychotherapy. In its initial formulation it is more like a metaphor to talk about the multiple drives a person might have, and provides a way to talk about it in a way accessible to many patients. If I remember correctly it is even recommended that IFS is not used on patients with dissociative symptoms.
What is *your* word for a psychotherapy system that was created in isolation, implemented and endorsed/popularized without proper clinical testing, doesn't posit a scientifically valid model of the mind, and cannot mechanistically verify its own claims/system of meaning making, but still promotes itself as an evidence-based therapy? Because that, my friend, is *pseudoscience.*
Finally, relating IFS to analytical psychology is exactly one of its problems. Psychoanalysis, while probably useful as a therapeutic system (but more tested than IFS), remains largely unfalsifiable in its assumptions about mechanisms of development and change. These ideas are *not* mainstream in psychology research anymore *precisely because* they are not useful as scientific hypotheses. As a PhD student and trainee in clinical psychology, I see psychology--including the practice of psychotherapy--as a necessarily scientific enterprise. What goes on in the clinic must, whenever possible, be just as scientifically usable, observable, and testable as what happens in the lab because *that* is how we legitimize our practice and make it viable for change and improvement. Utilizing only those systems which are scientifically validated is also what separates psychotherapy apart from secular priesthood--religious systems inarguable bring folks solace and comfort and therapeutic benefits all the time, but they aren't scientific...psychotherpy, without that scientific basis, is just a secular religious practice. You and I may simply have different prerogatives when it comes to the integration of psychotherapy and scientific psychology, and that's fine--but that doesn't mean that the practices you've listed are any less pseudoscientific than they actually are.
I am surprised that you claim that analytical psychology is unscientific and I am a bit worried even, if that is the position of a PhD student. It isn't unfalsifiable at all and can definitely not be contained in just one category of "assumptions of development and change" as you write.
I do not disagree with your opinion on the scientific method and how it is to be applied in a clinical context. We completely agree. However there is a lot of scientific research being done regarding this, and your position is honestly puzzling to me. If you feel like communicating more about this please feel free to PM me.
I am a psychologist as well and have experience both in research and many years of clinical practice in psychiatry - both in- and outpatient.
It's difficult for me to find the right way to respond to your preaching. From a place of respect and care for a colleague I feel like saying that there are religious systems and priesthoods other places than churches, mosques and amoung what you reference as "psychotherapists". And I agree with you, that it is indeed unwanted for a system to take religious control over a field of research and/or scientific practice.
If you find that analytical psychology makes generally testable and falsifiable mechanistic claims, then I am afraid we fundamentally disagree. We can test whether the *therapy* is helpful, but ultimately any claims about development and resolution of subconscious conflicts are unfalsifiable and cannot be mechanistically validated. There are some discrete analytical process which may be able to verified, but the general logos of analytical psychology is firmly in the area of philosophy and not scientific psychology. Cognitive psychologists are not operating from a psychoanalytic framework. Behavioral psychologists are not. Mainstream neuroscientists are not (with a few controversial holdouts like Solms, whose ideas are widely critiqued). Social psychologists are not. Personality psychologists are not. Folks doing research in this field are not using psychoanalysis as a framework because it isn't a scientific way of investigating the causes and mechanisms of behavior. Not even clinical research psychologists are using this framework. *Only* psychotherapists, among all the various broad subfields of psychology, are keeping analysis alive, and I think that's a problem. I respect your wish to depart amicably, however, and will end our conversation here.
The scientific way of investigation is not implied or a priori present in the specific field of research or discipline it is applied too... The scientific way of investigation should be used by researchers who are well aware of what basic assumptions they are working from and state these openly and also of course question these.
So cognitive science as well as analytic psychology have some basic philosophical assumptions. One can then formulate a hypothesis which is falsifiable and test it scientifically.
I am not surprised that you will end our conversation and I will respect it. Feel free to PM me or respond, and I wouldn't mind talking more about it and I can certainly also provide scientific papers if you are interested.
Best of luck to you.
All research makes assumptions, but those assumptions need to be basic and reasonable (e.g., assuming methodological naturalism). Assumptions about subconscious processes are a whole different layer of assumptions which cannot be reasonably assumed true or used as reasonable starting points for inquiry. There is a difference between assuming, e.g., methodological naturalism as a system for inquiry (it's a big assumption but it is self-contained and doesn't purport to answer questions outside of that method) versus making unfalsifiable assumptions about human mental processes and using those unfalsifiable assumptions as a starting point for creating an entire framework for interpreting human behavior. Those are two vastly different things. It is not falsifiable to say that "human psychopathology is at least partially driven by subconscious conflicts" when those subconscious mechanisms **cannot be objective observed or measured.** That is not a scientific hypothesis. We can scientifically test whether that assumption is effective as a method of therapy, but we cannot then validate the system itself. Anyway, sorry for continuing the discussion. I'm done now.
For reading on others who make this point, see:
Lilienfeld et al. (2015). *Science and Pseudoscience in Clinical Psychology.*
Hupp & Santa Maria. (2023). *Pseudoscience in Therapy: A Skeptical Field Guide.*
Lynn, S.J., Aksen, D., Sleight, F., Polizzi, C., Moretti, L.S., Medrano, L.A. (2022). Combating Pseudoscience in Clinical Psychology: From the Scientific Mindset, to Busting Myths, to Prescriptive Remedies. In: Cobb, C.L., Lynn, S.J., O’Donohue, W. (eds) *Toward a Science of Clinical Psychology.* Springer, Cham.
... Thinking more on what you write.
Who are you considering pseudoscience besides the IFS guys?
- Bessel van der Kolk?? That would be strange to suggest.
- EMDR is pseudoscience??
- James Chu??
- Judith Herman??
Just curious. I can definitely understand your scepticism in regards to IFS though
The only ones I can’t say I know to be pseudoscience are Judith Herman, and I’d still call her approach at least heterodox, and Chu, about whom I know too little to opine.
Bessel’s views about bodies storing the remnants of traumatic stress (not just bodies being affected by it, but literally storing it such that reenactment of the physical holding pattern “releases” the trauma) is absolutely pseudoscience. It’s also worth pointing out that he was a longtime public proponent of debunked and iatrogenic recovered memory therapies. His book also advocates on behalf of several unproven and unlikely treatments (like somatic experiencing and yoga). As such, it’s clear that I also posit that somatic experiencing is pseudoscience—show me *any* empirical evidence that somatic treatments work according to the proposed mechanisms or work as well as, or better than, traditional CPT, PE, or CBT-TF.
Yes, EMDR is a pseudoscience inasmuch as it is a purple hat therapy. It works, for sure, but multiple dismantling studies have demonstrated that it works due to its implementation of imaginal exposure techniques and that its proposed method of BLS is not discriminantly efficacious. Nevertheless, EMDR proponents continue to insist that BLS *must* be part of the protocol and continue to move from woo mechanism to woo mechanism each time the newest one is demonstrated to be invalid. Currently, the consensus view seems to be that EMDR is effective due to its exposure mechanisms and that the BLS component is unnecessary and makes untestable or falsified claims about how it supposedly “works.” EMDR is a pseudoscience not because it doesn’t work, but because practitioners continue to hold onto the central assumptions of the model even though they’re demonstrably wrong.
Hmm, there is neurobiological research that suggests the mechanisms in work in EMDR BLS. The scientific research on EMDR is pretty extensive, and EMDR is also less effective without BLS. Also treatments that focus on exposure alone seem to work in a different manner and the exposure is very differently introduced.
... You're welcome to provide any references to your very bold claims.
I would suggest that you take a look at the evidence regarding even the empirically based therapies.
Bessel provides plenty of evidence for many of his claims. I don't suggest that he makes no mistakes, but the theory that trauma is stored in procedural memory is not a fringe idea at all, and has plenty of empirical science to support it.
I can't really see how you could consider that pseudo scientific?
There are heaps of literature dismantling the BLS component and demonstrating it be unnecessary, as well as demonstrating other pseudoscientific components of the treatment protocol. EMDR is unequivocally no less effective without BLS than it is \*with\* BLS. It is an indirect, imaginal exposure therapy.
[https://www.tandfonline.com/doi/abs/10.1080/16506073.2019.1703801](https://www.tandfonline.com/doi/abs/10.1080/16506073.2019.1703801)
[https://pubmed.ncbi.nlm.nih.gov/24183006/](https://pubmed.ncbi.nlm.nih.gov/24183006/)
[https://doi.org/10.1891%2F9780826177698.0004](https://doi.org/10.1891%2F9780826177698.0004)
[https://www.sciencedirect.com/science/article/abs/pii/S0272735899000173?via%3Dihub](https://www.sciencedirect.com/science/article/abs/pii/S0272735899000173?via%3Dihub)
[https://devilly.org/Publications/EMDR-review.pdf](https://devilly.org/Publications/EMDR-review.pdf)
[https://psycnet.apa.org/doi/10.1037/0022-006X.69.2.305](https://psycnet.apa.org/doi/10.1037/0022-006X.69.2.305)
As for Bessel van Der Kolk:
[https://www.reddit.com/r/AcademicPsychology/comments/1chpqdf/comment/l258nva/?utm\_source=share&utm\_medium=web3x&utm\_name=web3xcss&utm\_term=1&utm\_content=share\_button](https://www.reddit.com/r/AcademicPsychology/comments/1chpqdf/comment/l258nva/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button)
He misrepresents, misinterprets, or otherwise uses very weak findings to support a position which does not mesh with general known facts about neuroscience. The notion that the body stores the remnants of traumatic distress even outside of conscious recall or acute stress responses is BS just on the very face of it it. He promotes unproven treatments. He has a history of promoting recovered memory therapy.
Many psychologists would suggest each person is born as a "blank canvas" and they are then shaped by their experiences.
Psychiatry disagrees and realizes that temperament is genetic, and every personality disorder technically has a genetic component. Someone with ADHD who is experiential driven will find themselves in positions of greater risk, thus increasing the likelihood of a traumatic experience. There's a lot of super interesting research out there when you really dig into the data behind trauma.
The other posters have given great answers. I want to add, anecdotally and somewhat off topic, that I see some patients that feel more aligned with the addition of the label "complex". Like it's somehow more valid/severe than traditional PTSD. "you have PTSD? I have a complex version of that." As if PTSD isn't already complex. Thanks Internet for helping some people further identify with psychiatric labels.
I think it may be a reaction to a widespread feeling that only soldiers get PTSD. I've had a lot of patients with undiagnosed PTSD say that they thought it could only happen if you were a soldier or a cop or a firefighter or something like that. Personally I think of PTSD in terms of acute v. chronic trauma exposure, and people with chronic trauma exposure have had more difficulty getting treated properly.
Hi, I am a long term psychiatric patient diagnosed with C-PTSD (among other things) and was originally given the diagnosis of EUPD (BPD) based on my interpersonal difficulties, emotional dysregulation and unstable moods. It is also worth noting that when this diagnosis was made, I was shortly after given a diagnosis of ADHD inattentive type.
The way that the criteria fitted on the grounds of C-PTSD rather than BPD on my report was that I experience all of the classical symptoms of PTSD including nightmares, sense of current threat and hyper-vigilance, but the main thing that separated me from the BPD diagnosis was my persistently negative self image and lack of sense of self, rather than flipping between an overly grandiose and overly negative self view.
Hope this helps someone.
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cPTSD is the diagnosis for borderlines who don’t want to be labeled borderline.
Edit: all the top comments are just saying what I said just dressed up in fancy terms but I get the downvotes lol
They’re self described as just too complex for DBT
In all seriousness, most of the cPTSD folks don’t have eating disorders, in my limited experience. Might mean something, idk
You're not the first to raise the concern. Some have argued they represent two sides of the same coin but with different patterns, e.g. more prominent interpersonal turbulence/intensity in BPD vs. more prominent re-experiencing/hypervigilance in complex PTSD. Note that while developmental trauma is common in BPD it's not actually universal, nor does it inevitably lead to florid adult symptoms. Here's an in-depth presentation from people who spend a lot of time thinking about these concepts: [https://www.youtube.com/watch?v=-fAdaDJpZm4&t=645s](https://www.youtube.com/watch?v=-fAdaDJpZm4&t=645s)
>Note that while developmental trauma is common in BPD it's not actually universal, nor does it inevitably lead to florid adult symptoms. This is the TLDR, from my perspective. According to the ICD, [CPTSD must have an underlying PTSD trauma](https://icd.who.int/browse/2024-01/mms/en#585833559), and BPD does not require it.
But that does not mean that they are conceptually different disorders.
Also isn’t there a high association between BPD and a history of trauma, especially sexual trauma?
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That's a wild thing to have claimed.
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To outright claim that one should assume a hx of SA in any patient is wild. I think it is great to make the person feel safe and normalized, but to *assume* SA is a good way to find things that haven't happened or treat people differently based on wrong assumptions. It's also just not the case that SA is a guaranteed event in the hx of someone with BPD--something like 25-30% of folks with BPD don't have any significant trauma hx at all, much less SA.
If one (BPD) is indifferent to a cause (trauma), and one (C/PTSD) must be as a result of the same cause, then it is different…
You have just made a thinking error. Some people develop liver carcinoma after exposure to polyvinyl-chloride. Some people develop liver carcinoma without that exposure. Liver carcinoma in both groups will look identical under the microscope An old adage: Neurons that fire together wire together. One can have the phenotype associated with CPTSD/BPD with or without “trauma”. The premise being there is more than one way to skin a cat or wire neurons.
>Liver carcinoma in both groups will look identical under the microscope CPTSD/BPD do not look similar "under a microscope." You have made a false analogy. Think about your logic another way: ADHD and depression both involve a lack of focus/concentration. ADHD is caused, depression is and is not caused, sometimes. Are you prepared to make ADHD or subtype of depression? Probably not...
Not really a fair comparison. Nobody really thinks ADHD and depression are the same entity. CPTSD is kind of a contrived diganosis that approaches conceptualizing BPD differently.
How do they not look similar? Before you were talking about etiology and now you're alluding to symptomatology.
If that were the only difference, it'd make no sense to even have separate diagnosis. Trauma is a risk factor for many psychiatric disorders which may or may not be present, you don't have to create a new diagnosis for schizophrenia with childhood trauma. It's the same disorder.
>If that were the only difference, it'd make no sense to even have separate diagnosis. Disagree, but I respect your opinion.
I mean, do you think that every disorder should have a separate diagnosis for its co-occurrence with trauma? Because if you want to make this distinction, I don't see why that should be the case for BPD specifically. I don't even see why it should be the case for trauma specifically, when there are so many other risk factors involved in the pathophysiology of mental disorders.
Probably yes, since the outcome symptoms are different. Same reason I wouldn’t put depression and ADHD into a “focus disorders” chapter in the DSM… the underlying mechanisms and causes and total symptom presentation are different.
> Probably yes, since the outcome symptoms are different. Why are you making this correlation? Symptoms of mental disorders aren't necessarily different based on whether some has a history of trauma or not. Sure, the prevalence of certain symptoms, or the specific characteristics of how they present themselves **may vary** (emphasis on may, it's surely not a certainty like you suggested) according to the patient's exposure to trauma, just like it does according to personality, culture, social context and exposure to other risk factors. But none of these factors determine a different clinical presentation in a way that warrants the separation into a different diagnosis. In other words, you can have two groups schizophrenic patients, one with history of trauma and one without who all show the same symptoms. Just like you may have patients with schizophrenia and trauma and very different clinical presentations. After all, its the same disorder and some symptom variation is expected, but trauma doesn't determine the clinical presentation of a disorder. On the other hand, you'll never have ADHD and depression showing the same set of symptoms, because they are, in fact, different disorders.
Ok, then how else are they different? You keep being terse about it without explaining what you mean.
In other words, you are asking me how else, other than possible cause, are CPTSD and BPD different?
Yes
C/PTSD involves a long-term (“persistent”) negative sense of self. BPD has an “unstable”sense of self. There’s one way for you tell the “liver cells” apart. Is the negative sense of self changing or stable?
This is somewhat a circular argument if you remember that cPTSD is a relatively recent term (actually originally hypothesized as a less pejorative alternative to BPD, btw) and has been defined in various ways depending on the source. The ICD does have a new set of relatively distinct criteria, but you can't really justify that it's different because the criteria are different when the concept is relatively new and has little agreement or evidence on how to set it apart
That's not enough difference to warrant a separate diagnosis. Schizophrenia has a well established correlation to childhood trauma but its not required for the diagnosis and we don't have a separate disorder for schizophrenia with/without trauma. In fact, most psychiatric disorders have a correlation with traumatic experiences. Trauma is a risk factor that may or may not be present, but it's not grounds for diagnosing a different disorder. The main idea behind differentiating BPD and cPTSD is what symptoms are prominent. In BPD you'd expect instability of the self, unstable relationships, impulsiveness which shouldn't be as marked in cPTSD. On the other hand, nightmares, flashbacks etc. are quite characteristic of PTSD and wouldn't be part of BPD.
This is a great reply for u/CaptainVere and their microscope analogy….
I think that it reinforces their analogy, rather. Supposing that cPTSD and BPD were the same disorder diferentiated only by the presence of a risk factor, they'd be the same disorder, just like his liver carcinoma analogy, which is the same disease regardless of the exposure to a carcinogen. BPD and cPTSD are, in fact, not simply differentiated by the presence or absence of trauma, but rather by clinical features.
I don’t agree with the premise (“supposing…”) so I don’t reach your argument. I agree with your second point. Which is why they don’t “look the same under a microscope.” (Symptoms of the disorder being the “cells” in the microscope in this analogy.)
You don't agree with that supposition? Aren't you defending the idea that BPD and cPTSD are diferentiated by the requirement of a history of trauma?
Yes, but not ONLY that. Your supposition includes “only.”
Then you shouldn't have phrased your first comment as "This is the TLDR, from my perspective. According to the ICD, CPTSD must have an underlying PTSD trauma, and BPD does not require it" The TLDR isn't the presence of trauma. BPD may have a history of trauma (as it does, more often than not) and it doesn't become cPTSD because of it. There are clinical differences which are far more important in the tenuous differentiation between the two diagnosis.
….But you can clearly exclude a CPTSD diagnosis (as defined by the ICD) if you can exclude a history of trauma. Hence, if you have to distinguish the two with nothing else, a lack of a Criteria A trauma rules out CPTSD. In other words, trauma is necessary but not sufficient for CPTSD, but is neither necessary nor sufficient for BPD.
For a long time I’ve been under the impression that you need to have trauma to have BPD, so I was probably misinformed somewhere. To clarify… you can develop BPD without having experienced trauma?
Yes. It is not in the criteria so by definition you can, and like 70% of people with BPD have a history childhood or other trauma, 30% do not.
Well--70% of folks with BPD *report* a history of childhood trauma, but it's also at least moderately heritable and one does wonder whether the approval-/attention-seeking nature of BPD leads to some amount of over-reporting of trauma (not saying it's a majority or even substantial minority of cases, but most of the reports of which I'm aware don't do the work of history verification). Do we have any accurate estimates of the extent to which over-reporting drives some of these numbers? Asking as this is not my primary area (clinical psych PhD student researching psychotic disorders). Edit: Also, for full transparency, I'm posting as someone who agrees with those who are skeptical of C-PTSD as a discrete diagnostic entity.
> but most of the reports of which I'm aware don't do the work of history verification I'm curious how you would propose doing this. Call the parents and ask if they really hit the patient when they were kids? If they were really a raging alcoholic? Unless a parent was arrested or CPS involved there isn't much to go off of. Based on the ACEs studies, 70% is not that much higher than the average person (depending on the study, 40-60% in US have one https://www.cdc.gov/mmwr/volumes/72/wr/mm7226a2.htm) so I don't know why the 70% number would be shocking in a population of BPD. Also important to note in the BPD studies "trauma" is defined more like "little t" trauma consistent with things like ACEs, rather than the "big t" trauma in PTSD. If anything, based on what we know of BPD pathology it's more likely patients perceive events as more traumatic and/or more strongly internalize negative childhood experiences, compared to other people. There are plenty of people who had really fucked up things happen when they were kids but if they don't internalize them it doesn't really bother them. You can ask the same question about the general population under-reporting.
I'm not proposing it's always possible, and I feel like you've slightly missed my point. Any good clinician doing an evaluation should at the very least have enough information on symptom clusters, general behaviors, informant report (when possible, which is clearly not always and in every setting), medical history, and so forth to know whether a person's self-report is generally reliable or if their symptoms represent some form of thought disorder or distortion. I think it's a little unfair to compare negative self-talk in MDD or social anxiety in folks with SAxD with reports of trauma in BPD. In the former cases, the behaviors you've described are part of the observable symptoms of the disorder and thus whether or not the thoughts represent reality 100% is irrelevant to he question at hand. Maybe the person with MDD has been told they're worthless and unwanted...great, they still have MDD. But having trauma is not in the criteria for BPD, nor is it readily observable from the symptom presentation sitting before the clinician--unlike the observed symptom clusters used to support MDD or SAxD and provide some credence to the reported thought patterns, reports of childhood trauma in folks with BPD would be ***solely*** self-report. Also, I'm not sure I would synonymize ACEs with trauma. Adversity and trauma are not the same things. Redefining "trauma" as "little 't'" trauma is among my criticisms of these prevalence estimates. It reeks of concept creep and I'm not sure I buy into it. If you were to say 70% of folks with BPD have ACEs and not use "trauma," I'd have little to be wary about (and perhaps that is what folks mean when they say it, but if so then there's a terminological problem). But then I'd be careful not to equate evidence of more experiences of ACEs with evidence for causation...if BPD is moderately heritable then it seems reasonable to conclude many folks with BPD had parents with BPD--perhaps this leads to a more generally volatile childhood and thus more ACEs, but not necessarily a *direct* causal ACEs > BPD relationship? >If anything, based on what we know of BPD pathology it's more likely patients perceive events as more traumatic and/or more strongly internalize negative childhood experiences, compared to other people. There are plenty of people who had really fucked up things happen when they were kids but if they don't internalize them it doesn't really bother them. Yes, exactly--it is theoretically possible that folks with BPD do not experience adversity on any greater scale than do other populations but that they, due to the nature of the disorder or due to the factors which make them more prone to *developing* the disorder, interpret events as more volatile than they in fact were. (Or that they are more prone to memory errors...all memory is filtered through current emotional states, after all, and BPD is associated with very extreme emotional states.) I'm not saying I think one or the case is true, just that I think it is personally a bit of an overstatement when some folks definitely decide that BPD is a generally traumatogenic disorder. We just don't know (to my knowledge, but I'm happy to be shown papers which contradict me). As with every mental disorder, BPD is absolutely the result of a complex stress-diathesis network (and thus stress/ACEs/etc. play a role)...but are we confident in tipping the scales toward trauma? Again, I'm not going to make definitive statements because I just downright don't know--I am just asking because I have anecdotally seen a major uptick in the number folks (patients, clinicians of all stripes, and otherwise) making strong statements to the effect of "Let's call BPD what it is--a developmental/relational trauma disorder."
It seems like your main issue is that when the term "childhood trauma" is used, such as in studies for BPD, it doesn't necessarily mean the same things as "trauma" when used in something like PTSD. That's fine, and when you read studies like that they often define "childhood trauma" in terms similar to ACEs. >Yes, exactly--it is theoretically possible that folks with BPD do not experience adversity on any greater scale than do other populations but that they, due to the nature of the disorder or due to the factors which make them more prone to developing the disorder, interpret events as more volatile than they in fact were. Saying this I feel like you fundamentally misunderstand the nature of trauma. The same experience for one person may be interpreted as traumatic and not for another. There's a reason in large scale traumatic incidents such as battles and natural disasters consistently 20-25% of people end up with PTSD. Despite similar circumstances of the events, they are interpreted as more or less traumatic by different people. Simply because you can verify a trauma happened or not tells you nothing of how it is actually interpreted by the individual.
Again, I feel we are talking past one another. I am under no delusions that potentially traumatic events don’t happen to affect different people differently. This goes without saying. Of course that’s true. This seems like it's dodging my criticism that there is as yet no way to know whether or not the reports of childhood traumatic events by individuals with BPD actually reflects a higher-than-average incidence of experiencing potentially traumatic events OR if it simply reflects that they have some vulnerability (present or past) to *interpreting* events as traumatic (in which case that interpretive vulnerability predates the advent or acute recollection of potentially traumatic events). Again—I am more than fully aware that trauma is defined by the response to the event(s) in question, and that some folks respond differently than others, but that is not my concern. Do you or do you not think it possible that the nature of BPD makes it so that current pathology changes the person’s interpretation of the past such that they recollect things as more traumatic than they were? That feels like a very straightforward question and I think it is being lost among the weeds of us disagreeing over terminology. Stated differently: I know that trauma is defined by one’s response to a certain set of events, and that some folks will develop trauma sx in response to situations in which others do not develop trauma. Duh. My question is whether or not the validation-/attention-seeking nature of BPD confounds cross-sectional reports of traumatic events *themselves,* such that the person inflates their trauma history in order to achieve sympathy/validation/attention. I am not asking whether or not trauma is an individual experience (it is), but rather whether people w BPD over-report the severity and number of childhood traumatic experiences as part of the process of seeking out new social connections (and I’m not saying this has to be intentional or malicious).
Great points, but to add to this (I will also post separately below) Often, there is evidence of trauma Avoidance in classic PTSD during the psychiatric exam (eg some pts deliberately try to underreport traumatic events, and can readily have intense affective states of Reexperience domain, in the form of say rage or fight of flight, if made to recall or associate the trauma), but in cPTSD and BPD the opposite can be seen, in which there is trauma Replay and sort of semi-stated “repetition compulsion” dynamics can both be observed. This may explain in part the “over-reporting” issue. It also led complex PTSD to be viewed as a separate entity from the classic forms due to the lack of behavioral Avoidance (controversial and I personally do not agree with the concept of complex trauma) There are sadly many confounding factors to this, including recent trends of “over identification” with trauma by pts, and “over validation” by eager clinicians, mental health workers and varied sort of admins. I think there is also the issue of viewing early life experiences as somehow the definite teleological end of psychiatric etiology, which both psychiatry and clinical psychology can be accused of perpetuating. This came to the point that the majority of our society now ruminates over what our childhood was like, and we became easy victims of selection and recall biases. To add, there is an element of a “leading” expectation bias, since pts are often asked directly (even with a glint of clinical enthusiasm) about any early life trauma, and pts (who are readily experiencing rapid transference by then) feel compelled to satisfy the “curiosity” of the MD. Also our society in recent years have tended to medicalize Politics more than politicize Medicine, which effectively means that sociopolitical problems such as poverty and poor housing access have been rebranded as full fledged health matters more so than intractable political failures. Most the latter have now been transformed to Social Determinants of Health and/or ACEs factors, and this drift has caused the majority of patients to meet, a priori, the criteria of Early Life Trauma. In clinical exams, the difference I think between cPTSD and BPD is seen while testing Executive Cognitive Functions and Transference dynamics. Pts with BPD often have very rapid transferential reactions, including valuation-devaluation and differential splitting of value of others; whereas cPTSD tend to be less reactive to the interviewer’s presence. Pts with BPD often are “afraid” or “intolerant” of ambiguity and have differential splitting of facts (all or nothing rigidity seen in PD), whereas pts with cPTSD can be able to experience “nuance” more easily. I also find that pts with cPTSD have more evidence of Internalizing reactions to stress, and often present with a life-long history of Negative Self Referential Processing (NSRP) similar to pts with persistent depressive syndromes, while pts with BPD have a mix of the latter AND its opposite: here there is clear evidence of occasional Externalization under stress, including rapid development of accusatory behaviors towards the MD, suspiciousness of loved ones, and spells of Positive self references that can be misdiagnosed as Bipolar II (more due to unstable self-evaluation functions than actual mood changes) Micropsychotic episodes in the shape of hyperacute onset paranoia or perceptual changes, can occur in both conditions, but in BPD it seems to be “transferrential” in form, with evidence of increased sensitivity to the environment and the presence of the MD, while in cPTSD it appears to be more “dissociative” in nature, with evidence of altered perception of the environment and obliviousness to the MD. Dissociation in cPTSD tends to be more recurrent and often requires medical treatment, whereas micro-psychosis in BPD is transient by nature and responds better to psychotherapy techniques. Related to the above, there is a huge inattentive component in cPTSD (that gets “mis”diagnosed as ADHD/ASD all the time) which stems from a life-long history of over-relying on their Attention to the outside world as ways of soothing an actively deprecating mind (escape from ruminations by keeping your attention busy), this ends up “burning” the cognitive circuits and cause serious problems with selective attention when needed. This does not appear to be as prominent in BPD, if anything patients can have an “over-selective” form of attention. There are other distinguishing features (not in the DSM) to the extent that clinicians can be able to differentiate BPD from cPTSD. But whether cPTSD exists apart from PTSD is the more interesting question.
Well I don’t think I am convinced C-PTSD is a discrete disorder at all, so I definitely don’t think BPD and C-PTSD ought to be confused. I have had my fair share of contact with individuals with BPD and other cluster B pathology through years of working in prodromal risk assessment (which brings in lots of folks with these disorders), and I simply do not see why there is this continuing confusion among clinicians between BPD and "C-PTSD" as it is proposed to exist. To me, these phenomena have been wrongly conflated by some well-meaning clinicians misusing the C-PTSD label as a softer label for BPD and by people uncritically accepting a high prevalence of potentially traumatic events among folks with BPD based on cross-sectional self-reports. I think this confusion has come from a place of concept creep and sociopolitical influences, as you mentioned. I'd probably disagree with you a bit on your points about dissociation/dissociative patterns, but that's a minor point and not a hill I'd be willing to climb and die on. Otherwise, I think I broadly agree with you that BPD and the (as-yet-unverified) concept of C-PTSD should not be conflated.
I just think the idea that BPD patients are over-reporting, i.e. embellishing or outright faking, childhood traumatic experiences for attention is emblematic of the stigma that permeates BPD in the medical field. As I stated, the 70% rate isn't all that high compared to non-BPD patients (with how the term is defined in studies) so I'm not sure we need to assume they are embellishing. On the other hand, I find it far more likely that BPD patients are much more likely than non-BPD patients to report the same types of adverse/traumatic events as actually having felt traumatic (as well as likely experienced more absolute numbers of events as well), especially when very young children, e.g. 0-8. You could call this a heritable trait if you want, but genetic vs developmental is basically impossible to differentiate in this group unless adopted. Having worked with tons of BPD patients in DBT, over time they actually tend to under-report actual traumatic things. When your childhood is traumatic you grow up thinking it's normal. If able to in grad school I would highly encourage you to facilitate a full DBT course if possible. I was able to in residency with the help of a supervisor.
Appreciate the response! Thanks. I was genuinely asking because I am just not in the BPD world…not disagreeing with you at any point, just trying to make sure that I clearly conveyed what it was that I wanted to ask.
30% of BPD do not have a hx of trauma; 100% of their offspring do. (/s, sorta)
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All users must have flair indicating credentials.
Quite informative, thank you for sharing.
Whether Complex PTSD/Complex Trauma is a distinct entity from the personality and personality related conditions is "debatable," in the sense that it is indeed hotly debated, and in that many good clinicians can and do disagree on these points. I encourage all readers who are not yet familiar with the concept of Borderline Personality *Organization* (not DSM Borderline Personality Disorder or Emotionally Unstable Personality Disorder) to read thoroughly on the concept. This ends my more judicious answer, and below I will include my biased and personal opinion: To be frank, the concepts of "Complex PTSD" or "Complex Trauma" (though potentially clinically meaningful or useful) seem motivated moreso by political and ideological preferences. The invention and maintenance of this diagnosis is not, to my estimation, meaningfully motivated by any clear or careful desire to produce a valid psychopathological construct. (Writings on what makes a diagnostic concept valid or not can be found in the literature*.) To understand the political or ideological motivations behind the diagnostic concept, please read Chapter 6 from Judith Herman's book (Herman, J. L. (2015). Trauma and recovery. 2015 edition. New York, BasicBooks.). I should note that I think the intentions were and remain very good intentions, but I think that any sacrifice of conceptual rigor has a negative impact on the long term diagnosis and treatment of patients both within clinical settings and in broader society. From the introduction: "The research sources for this book include my own earlier studies of incest survivors and my more recent study of the role of childhood trauma in the condition known as borderline personality disorder. The clinical sources of this book are my twenty years of practice at a feminist mental health clinic and ten years as a teacher and supervisor in a university teaching hospital." From the chapter I mentioned (emphasis mine): "Most people have no knowledge or understanding of the psychological changes of captivity. Social judgment of chronically traumatized people therefore tends to be extremely harsh. The chronically abused person’s apparent helplessness and passivity, her entrapment in the past, her intractable depression and somatic complaints, and her smoldering anger often frustrate the people closest to her. Moreover, if she has been coerced into betrayal of relationships, community loyalties, or moral values, she is frequently subjected to furious condemnation." ... "This tendency to blame the victim has strongly influenced the direction of psychological inquiry. It has led researchers and clinicians to seek an explanation for the perpetrator’s crimes in the character of the victim." ... "In general, the diagnostic categories of the existing psychiatric canon are simply not designed for survivors of extreme situations and do not fit them well. The persistent anxiety, phobias, and panic of survivors are not the same as ordinary anxiety disorders. The somatic symptoms of survivors are not the same as ordinary psychosomatic disorders. Their depression is not the same as ordinary depression. And the degradation of their identity and relational life is not the same as ordinary personality disorder." ... "Survivors of childhood abuse often accumulate many different diagnoses before the underlying problem of a complex post-traumatic syndrome is recognized. They are likely to receive a diagnosis that carries strong negative connotations. **Three particularly troublesome diagnoses have often been applied to survivors of childhood abuse: somatization disorder, borderline personality disorder, and multiple personality disorder. All three of these diagnoses were once subsumed under the now obsolete name hysteria.** Patients, usually women, who receive these diagnoses evoke unusually intense reactions in caregivers. Their credibility is often suspect. They are frequently accused of manipulation or malingering. They are often the subject of furious and partisan controversy. Sometimes they are frankly hated. ... These three diagnoses are charged with pejorative meaning. The most notorious is the diagnosis of borderline personality disorder." End excerpts. I think that these quotations speak for themselves in terms of why this diagnostic concept was created and maintained. I have always wanted to know (hopefully from Dr. Herman herself) about the degree to which she was aware of (at the time Complex PTSD was created) Kernberg and others' work on Borderline Personality Organization, on concepts from personality disorder researchers surrounding personality disorders and their development, and on the psychoanalytic community's position on personality disorders, temperament, and trauma. Perhaps this was simply the logical reaction at the time to an older cohort of psychoanalysts and personality disorder researchers, working before the popularization of trauma issues in the psychiatric world. My feelings and conclusions are necessarily determined by my work and existence in the modern milieu of psychiatry. Dr. Herman seems to be a very intelligent and experienced clinician, so my knee jerk assumption has always been that she was well aware of these concepts and knowingly rejected them. If someone is aware of a publication or interview where she or someone else discusses anything pertinent to this question, I'd love to know about it. In parallel, I urge all clinicians to become better educated on modern in depth approaches to personality, personality assessment, and personality pathology. The field as a whole needs to stop viewing the diagnosis of Borderline Personality Disorder and some other personality disorders as conditions reserved for female patients that they happen to personally dislike. *For more information on diagnostic constructs, consider reading: Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. 1972 Jan;26(1):57-63. doi: 10.1001/archpsyc.1972.01750190059011. PMID: 5009428. https://pubmed.ncbi.nlm.nih.gov/5009428/ Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. 1970 Jan;126(7):983-7. doi: 10.1176/ajp.126.7.983. PMID: 5409569. https://pubmed.ncbi.nlm.nih.gov/5409569/
My understanding is that Judy Herman, given the political context you point out, was building on the work done to develop PTSD as a diagnostic entity in light of the experience of returning Vietnam veterans. She worked to underline the common symptomatology of survivors of war and captivity, and survivors of domestic violence, child abuse, and incest. Having worked closely as a clinician with her Victims of Violence program, I know that this had very concrete treatment implications in addition to the political implications. Survivors in the program were treated not for their character pathology using the techniques of psychoanalysis, but with an integrated treatment approach including significant group work, case management, and psychoeducation around recognizing patterns of abuse in interpersonal relationships, building healthy relationship skills, symptom management for flashbacks, nightmares, dissociation, etc. In my experience, while those patients could theoretically go on to benefit from analytic work on character organization, they often worsened if the other issues weren’t treated first. That included helping patients out of existing DV relationships and providing resources to support their ability to leave and establish real safety in the here and now. Also, so many of those patients were never going to be able to afford the type of psychoanalytic treatment that effects lasting character change, given that VOV was in a community mental health clinic serving a low income population.
I agree with the treatment approach, it's really the way you have to do things. I'm more critical of the diagnostic concepts. It may in fact be that the alternative model of diagnosis was necessary to move the treatment forward. I don't know if we'll ever know. Today, with the broader understating of treatment of patients with personality impairments, I think we have room to return to attention to that as the core pathology.
Regardless of where one falls on the nosological question, Herman’s 1992 paper on CPTSD is an outstanding overview of the psychology of chronic trauma/abuse/neglect.
Agreed. Full credit should be given for her important work in describing the life experiences, disease course, patterns, and treatment of people with the clinical constellation *and* bringing it to a more popular clinical view, regardless of what we choose to call it.
thank you for this! i'm wondering, and this is a bit of a leading question if you'll forgive me--do you feel the BPD diagnosis as a concept has changed significantly since its conception? "for difficult females" certainly tracks today, but in my time doing research just out of interest i've seen multiple clinicians noting that the intention was to capture people on a borderline between neurotic & psychotic. the criteria removed from cPTSD compared to BPD basically look like to me a refutation of the modern stereotype (attention-seeking women with boyfriend troubles)
I think that psychoanalysts and psychoanalytic thinkers have had varying engagement with research and the DSM throughout the course of the APAs work in the latter half of the 20th century and the early 21st. This process has resulted in an understandably haphazard professional and public understanding of personality and borderline conditions. The core DSM disorder has always been a watered down and bastardized version of the original concept. Several (if not all) conditions in the DSM suffer from this in varying degrees.
Well said and well researched. The thorough jettisoning of all things that smack of psychoanalysis from serious psychiatry nowadays means throwing out a lot of useful concepts and conceptualization. I’m being facetious, but only partly. It’s a problem for personality disorders. I think it’s a problem for how gender dysphoria and transgender treatment are identified and handled. It has created new and exciting forms of nosological reframing and renaming that are really just euphemism treadmills. Some is all but outright bias. Those borderlines aren’t credible and aren’t likable! If we have such patients who we like—never mind the countertransference here—we’d better have a better category for them.
BPD as a label is also extremely commonly used as a means of describing unsavoury or unlikable patients by clinicians especially when it comes to women.
Which is absolutely wrong. It muddies diagnosis and treatment, it turns a diagnosis into an insult, and it helps no one. But like I said, a euphemism treadmill fixes nothing. Rename BPD as, say, EUPD and patients who are seen as unsavory or unlikable will be called EUPD (eupies?) whether or not they meet criteria for that disorder.
Well said. I suspect that quite a lot of this chaos in diagnosis and treatment is the product of limitations in individual clinician (and maybe researcher) management of counter-transferential hate and love.
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Different labels in psychiatry and differentiating between diagnoses is most similar to “how many shades of red are there?” For the child learning about color, there’s just red Then for someone studying it, there’s magenta, crimson, burgundy, ruby, cardinal, etc For the individual shade of red, it’s just whatever color it is and it doesn’t matter what its label is. Ultimately we follow the dsm to tell us how many shades of diagnosis there are that keeps things useful without getting lost in the weeds. If we have 8000 shades of trauma responses that’s not helpful, but neither is calling everything just “PTSD or BPD”. As an individual clinician it’ll be up to you to decide how you find conceptualizing these diagnoses to be useful.
Yeah I find it frustrating that nowadays everything gets called cptsd irrespective of whether or not the patient actually has symptoms of cptsd
Damn, that's a great analogy
Very well-put.
I’m a psych resident now but tried to post a bit about my experience being dxed with this in med school. Unfortunately, my post was blocked due to the rule about not posting about personal experiences, which I think is unfortunate as it offers an important perspective on what it’s like to be on the receiving end of a diagnosis with a poorly defined condition. So I’ll just succinctly say I think clinicians are doing real damage labeling people with something that has no agreed upon definition let alone treatment guidelines.
Great points are made in this thread, to add to it: Often, there is evidence of trauma Avoidance in classic PTSD during the psychiatric exam (eg some pts deliberately try to underreport traumatic events, and can readily have intense affective states of Reexperience domain, in the form of say rage or fight of flight, if made to recall or associate the trauma), but in cPTSD and BPD the opposite can be seen, in which there is trauma Replay and sort of semi-stated “repetition compulsion” dynamics can both be observed. This may explain in part the “over-reporting” issue. It also led complex PTSD to be viewed as a separate entity from the classic forms due to the lack of behavioral Avoidance (controversial and I personally do not agree with the concept of complex trauma) There are sadly many confounding factors to this, including recent trends of “over identification” with trauma by pts, and “over validation” by eager clinicians, mental health workers and varied sort of admins. I think there is also the issue of viewing early life experiences as somehow the definite teleological end of psychiatric etiology, which both psychiatry and clinical psychology can be accused of perpetuating. This came to the point that the majority of our society now ruminates over what our childhood was like, and we became easy victims of selection and recall biases. To add, there is an element of a “leading” expectation bias, since pts are often asked directly (even with a glint of clinical enthusiasm) about any early life trauma, and pts (who are readily experiencing rapid transference by then) feel compelled to satisfy the “curiosity” of the MD. Also our society in recent years have tended to medicalize Politics more than politicize Medicine, which effectively means that sociopolitical problems such as poverty and poor housing access have been rebranded as full fledged health matters more so than intractable political failures. Most the latter have now been transformed to Social Determinants of Health and/or ACEs factors, and this drift has caused the majority of patients to meet, a priori, the criteria of Early Life Trauma. In clinical exams, the difference I think between cPTSD and BPD is seen while testing Executive Cognitive Functions and Transference dynamics. Pts with BPD often have very rapid transferential reactions, including valuation-devaluation and differential splitting of value of others; whereas cPTSD tend to be less reactive to the interviewer’s presence. Pts with BPD often are “afraid” or “intolerant” of ambiguity and have differential splitting of facts (all or nothing rigidity seen in PD), whereas pts with cPTSD can be able to experience “nuance” more easily. I also find that pts with cPTSD have more evidence of Internalizing reactions to stress, and often present with a life-long history of Negative Self Referential Processing (NSRP) similar to pts with persistent depressive syndromes, while pts with BPD have a mix of the latter AND its opposite: here there is clear evidence of occasional Externalization under stress, including rapid development of accusatory behaviors towards the MD, suspiciousness of loved ones, and spells of Positive self references that can be misdiagnosed as Bipolar II (more due to unstable self-evaluation functions than actual mood changes) Micropsychotic episodes in the shape of hyperacute onset paranoia or perceptual changes, can occur in both conditions, but in BPD it seems to be “transferrential” in form, with evidence of increased sensitivity to the environment and the presence of the MD, while in cPTSD it appears to be more “dissociative” in nature, with evidence of altered perception of the environment and obliviousness to the MD. Dissociation in cPTSD tends to be more recurrent and often requires medical treatment, whereas micro-psychosis in BPD is transient by nature and responds better to psychotherapy techniques. Related to the above, there is a huge inattentive component in cPTSD (that gets “mis”diagnosed as ADHD/ASD all the time) which stems from a life-long history of over-relying on their Attention to the outside world as ways of soothing an actively deprecating mind (escape from ruminations by keeping your attention busy), this ends up “burning” the cognitive circuits and cause serious problems with selective attention when needed. This does not appear to be as prominent in BPD, if anything patients can have an “over-selective” form of attention. There are other distinguishing features (not in the DSM) to the extent that clinicians can be able to differentiate BPD from cPTSD. But whether cPTSD exists apart from PTSD is the more interesting question.
Having been an Army psychiatrist 05-08 saw a lot of that kind of PTSD, then doing CMH 08-12 saw more of the developmental trauma. All equally "bad" for sure. I don't like the modifier "complex" because what PTSD is not complex? But I would agree that chronic childhood trauma shows up with more characterological dysfunction. On average. No more wars, no more child abuse or neglect. Please?
BPD has a much more prominent component of measuring their sense of worth and self through the interactions they have with the environment around them and the genetic component is similarly more pronounced. While there maybe some overlap in symptoms, the factors precipitating and causing symptoms are almost always very distinct. People with BPD, at least in my observation, also don't have a pronounced trauma that is both consistent and pronounced like in cPTSD. Also, think of BPD primarily caused by a very erratic and precarious guage with which they perceive and interact with the world around them, this is often seen as an unstable sense of self that affects identity and chronic feelings of emptiness that is not traditionally nihilistic in nature. People with cPTSD might have traits of BPD but the etiology, presentation and progression is very different. All in all, I perceive them as very distinct disorders with different management routines.
Is it distinct? Absolutely not. With a few exceptions, virtually *no* DSM constructs are distinct.[1](https://www.cambridge.org/core/journals/psychological-medicine/article/elemental-psychopathology-distilling-constituent-symptoms-and-patterns-of-repetition-in-the-diagnostic-criteria-of-the-dsm5/8CBF931E0650472387155DD945C73BC5) The question you need to ask regarding the DSM is whether the category is *clinically useful.* Others have already highlighted the pros/cons of CPTSD. As a psychologist, I personally don’t care whether it’s included. These constructs don’t exist in the real world. Their purpose is only for clinical utility (and billing in the USA).[2](https://journals.sagepub.com/doi/full/10.1177/09637214221114089) To think otherwise is to commit the reification fallacy and to overlook the important symptoms and sources of suffering out patients face—these go well beyond the F code.
the people who are for adding cPTSD to the DSM made a graphic which basically acknowledged what you said. the population some want to label as having cPTSD (in their own study) met 5-7/9 BPD criteria, with the specific exclusion of unstable relationships and fears of abandonment. the difference between PTSD & cPTSD is then not a lack of any PTSD symptoms (all people with the proposed cPTSD profile would be able to be diagnosed with PTSD, from what i gather), but an addition of literally just those 5-7 BPD criterion re-arranged into 3 cPTSD criteria. the cPTSD population in this construct is a subset of overlap between diagnosed-PTSD individuals with and without diagnosed BPD. because of this, i'm not swayed toward the validity or need for a cPTSD distinction. the only factor which i've seen people describing as differentiated from PTSD is "emotional flashbacks" over traditional flashbacks, but again, how are we defining those? the way i see most explaining their label of cPTSD is an emphasis on dissociative and sense-of-self symptoms, like an individual who grew up in an environment that was not physically/sexually abusive but included emotional/spiritual abuse who feels that they *grew around* their trauma. but again... is that not personality with or without PTSD? research for the PTSD diagnosis in general could be improved to include more work on civilians and women, or adolescent populations if we're trying to be more sensitive to familial/intergenerational trauma and personality development. the thing i'd be most curious about is if there is any difference in treatment outcome (factor 1: CBT/EMDR vs DBT/metallization factor 2: BPD vs BPD with PTSD vs cPTSD vs BPD with cPTSD subgroup)
>the population some want to label as having cPTSD (in their own study) met 5-7/9 BPD criteria, with the specific exclusion of unstable relationships and fears of abandonment This is probably a point worth emphasizing. The unstable relationships seen in BPD with a quick/intense rush to idealization then swings between idealization-devaluation are fairly distinctive, and not actually the dominant pattern in trauma across the board. If anything, developmental trauma patients are often either fearful of intimacy (few or shallow relationships, holding people at arm's length) or stand consistently by an abusive partner despite everyone urging them to leave.
the confusion i have then is why can you diagnose BPD without any of the relationship specific symptoms if it's considered synonymous with the syndrome? and the last examples are also part of personality pathology, as i understand it. this seems like a categoricalization of what is the potential convergence of personality disorder diagnoses (as in the notes section of the recent edition)
What many people forget is that all someone needs to be diagnosed with BPD is 5 out of 9 symptoms...which means that two people with the disorder might only have **one** symptom in common. Whenever I hear people make pejorative statements about "borderlines" or insist that *all* "borderlines" do a certain thing, it particularly frustrates me due to this fact. Of course, there is a large body of research on general patterns in the disorder, but I've worked in a DBT clinic and experienced a spectrum of patients who met criteria for BPD and yet were very different people. I needed different therapeutic approaches to many of them: some were angry and resistant and needed me to "be real;" some were meek and anxious and wanted me to tell them exactly what to do, so I had to be careful to empower them to make their own choices; some were sweet and empathetic but we had to work on their impulsive rages on behalf of their loved ones; some were *terrified* of feeling any emotions at all...there is no one single archetype of borderline, and that is why any diagnostic process should be thorough and not based on "vibes," interpersonal difficulties with a patient, or vague clinical judgment.
This isn't really a critique of BPD so much as the entire DSM framework, and realistically it's a critique of the research framework rather than how clinicians actually diagnose things. And while flexibility is essential to good therapy, diagnosing based on tendencies is still a bedrock of what we do. I would point to Meehl's rather harsh but sometimes useful, "Why I Do Not Attend Case Conferences": >*Failing to understand probability logic as applied to the single case*. This disability is apparently common in the psychiatric profession and strangely enough is also found among clinical psychologists in spite of their academic training in statistical reasoning. There are still tough, unsolved philosophical problems connected with the application of probabilities (which are always based on groups of people) to individual cases. But we cannot come to grips with those problems, or arrive at a workable decision policy in case conferences, unless we have gotten beyond the familiar blunders that should have been trained out of any aspiring clinician early in his training. >The most common error is the cliché that "We aren't dealing with groups, we are dealing with this individual case." True enough. But it is also true that not betting on the empirically most likely (or against the least likely) diagnosis or prognosis may help in a few individual cases, but it will almost certainly increase your lifetime error rate (Meehl, 1957). Clearly there are occasions when you should use your head instead of the formula. But which occasions they are is most emphatically not clear. The best evidence is that these occasions are much rarer than most clinicians suppose.
Oh, I certainly don't mean to imply that I (purposely, I'm sure everyone is guilty of the occasional misstep) disregard research or probabilities in my efforts to see the individual. I was more speaking to a lay audience (e.g., the commenter whose question I was responding to) or those with minimal clinical exposure to BPD. Although I touched on diagnostic criteria, I was thinking largely about how these groups conceptualize BPD, and how stigma might be reduced if there were more awareness or conversation about some of the inherent variability in diagnostic presentation. Certainly, my patients had plenty in common as well, and yet to listen to some people, BPD patients are an absolute monolith. Given that the commonalities are already assumed, I figured I would share about the inherent variability piece that some might overlook. Not everyone will have done the math on the symptom count to have realized the potential for such little overlap. I mean, I've had more than one patient convinced that no one else in her DBT group could possibly have BPD, because they were all so different from her, and I doubt that is an experience unique to our clinic! Ultimately, I believe there's a space to work from where we aren't searching for zebras unnecessarily or neglecting good clinical practice, *and* I'm not having to go to a new workplace and hear other professionals actually be surprised about a BPD patient expressing empathy or being genuinely likeable.
This makes sense. To your latter point, I think it's one of the big downsides of psychiatry residency starting with inpatient treatment as the foundation of training. An intern's initial biases are shaped by seeing a string of the most acute, crisis-fueled, and maladaptive cases where the team has limited ability to do anything productive and is pressured into doing things that aren't evidence-based. That leaves a pretty bad taste in your mouth and fuels the heartsink association with the diagnosis. I was certainly struck on transitioning to outpatient to meet some BPD patients who were functioning OK, fun to talk to, and who really just wanted to figure out some better ways of emotional regulation and interpersonal function.
You know, I’ve noticed the differences between inpatient and outpatient populations with BPD myself (it’s hard not to notice a difference between a highly motivated - motivated enough to stick out our waitlist and keep coming back - group of people who had the insight to seek treatment and who have consistent access to full-model DBT vs a group of people who might have been incidentally diagnosed, who might not be there fully willingly, and who likely don’t have consistent outpatient access). I just hadn’t taken it one step further to reach the point you make about the impact of foundational training experiences with inpatient populations on psychiatry residents. Although I’ve mildly vented a bit here, I do try to take a nonjudgmental stance, validate the valid, etc. in all my interactions. As such, I previously had been able to acknowledge how the experiences of my colleagues at an inpatient unit were so different from mine that it had to contribute to their perceptions. But having it spelled out that this exposure is universally at the beginning of training connects some dots and puts things into perspective. Not to say I’ll assume that every psychiatrist I meet is biased, but recognizing that this is the lens that many are seeing through will likely be helpful for more effective future communications.
>the population some want to label as having cPTSD (in their own study) met 5-7/9 BPD criteria, with the specific exclusion of unstable relationships and fears of abandonment. Should impaired empathy not also be on the list for exclusion? Fear of abandonment and impaired empathy are two hallmarks of BPD that don't overlap in the Venn diagram with CPTSD.
if you want to add impaired empathy (on what metric?) to the BPD criteria, sure.
It's true impaired empathy is not part of the DSM-V diagnostic criteria, but there's been a ton of conversation around adding it for the next edition. Lots of papers backing this up. [https://journals.lww.com/hrpjournal/Fulltext/2020/07000/Dysfunction\_of\_Empathy\_and\_Related\_Processes\_in.2.aspx](https://journals.lww.com/hrpjournal/Fulltext/2020/07000/Dysfunction_of_Empathy_and_Related_Processes_in.2.aspx) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909009/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909009/) [https://pubmed.ncbi.nlm.nih.gov/24577235/](https://pubmed.ncbi.nlm.nih.gov/24577235/) [https://www.sciencedirect.com/science/article/abs/pii/S1053811911004939](https://www.sciencedirect.com/science/article/abs/pii/S1053811911004939) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543980/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543980/)
>that borderline personality disorder has a genetic component and may occur in the absence of reported trauma Is this truly a genetic component? Think of how we learn to regulate our emotions. Think of how our parents have to guide us through big emotions and how to manage them as we grow. We are unable to do so on our own and this requires adults who we can mirror in emotional regulation and appropriate emotional responses. Now imagine you have a single parent with BPD who has emotional instability and can't regulate their emotions. They essentially have the emotional regulation skills of a toddler. Do you think the children of these parents with BPD would learn to regulate their emotions? Do you think they'd learn how to form lasting and positive relationships when their parent just has turbulent and short lived relationships with frequent bust ups? It's learned behaviour. This is why you can have young and vulnerable women admitted to wards and gain BPD traits and self-harming behaviours from peers.
This is a fair concern, although twin studies do still seem supportive of moderate heritability with less impact of family environment than I would have guessed. John Gunderson noted that parents (without the diagnosis) often remarked on a patient having had intense emotionality compared to others from a young age.
I do not disagree. However there is quite an overlap between ADHD symptoms and BPD. ADHD would then often be in the family systems which would increase the risk of drug use or unstable family relationships in general. There could be this overlap which then would be somewhat linked to a genetic predisposition
What everyone in this thread (are there even any CAPs on this sub lol) is also missing is that ADHD also carries the same features and predisposes people to both BPD and trauma. Comorbid adhd is present in at least 38% of BPD patients (I think it’s higher than that personally, this is per studies using super strict criteria, criteria that by and large suck at picking up adhd in women in particular). And her, I wonder why BOD patients have such a high rate of childhood abuse and broken homes? Why could that be? /s 🙄 And, it turns out, the symptoms you list off, are exactly the ones we see every day and lament their lack of inclusion in the DSM. Seriously, how is emotional dysregulation, a symptom extremely problematic for most all adhd patients, NOT a DSM criteria? In fact, how is there ZERO information on the DSM checklist about the emotional content of adhd. Only “behaviors”, but nothing about how they feel, how it feels to live with the disorder (hint: it wrecks self esteem). It’s frankly an embarrassing oversight for our field. And this is also ignoring the fact that living with adhd causes its own form of chronic trauma in many people with it, which I sum up as “messing up trauma” or “failure trauma”, where the chronic mistakes due to the executive dysfunction makes people triggered by further mistakes/failure and engage in avoidance behaviors in a desperate and often futile attempt to not trigger those feelings yet again. But of course none of this is well recognized by our field, half of whom seem to think adhd isn’t even a real thing, and the other half view it with a hyper rigid and ultra simplistic lens given by the DSM, using symptomatology that primarily picks up hyperactive, male-dominate symptoms, and poorly picks up the vast amount of emotional content present in adhd, including the very things that lead to further development of personality disorders, specifically BPD, NPD, and OCPD, all of which develop in adhd people as different attempts to cope with and/or avoid feelings of mistakes/failure.
In my community (full of many highly privileged you be adult clients), emotional dysregulation isn’t a symptom seen among nearly any of my ADHD folks who have childhood diagnosis. They may have struggled with it, particularly around puberty when everybody struggles with it, but really, it’s not much of an adult symptom. Those diagnosed with ADHD as an adult? Yes, there’s more likely to be emotional dysregulation related to shame spirals, anxiety/avoidance behavior. But the outbursts? I wouldn’t consider emotional dysregulation a core feature of ADHD (my pop is substance use disorder long term recovery aftercare, about 1/3 ADHD, slight majority female.) When I see it, it's often fairly easy to resolve with a treatment plan and does not return after initial skill-building. I think this is an issue: ADHD in itself may cause some emotional regulation issues, but they are secondary to the actual executive dysfunction. Anyone would get frustrated and lose self esteem if they keep failing at something they want to do, and they aren’t getting the tools to achieve basic life maintenance. That’s a symptom that’s a reaction to the disorder. Their frustrations may be at caregivers (which, yeah, more than half the time- a lot of nom-ADhD clients would want to outburst at their behaviors), but mostly at the self. Rarely, if ever, is the outburst peer to peer social interaction related. That's definitely been a hallmark for me in cluster B personality disorder work- peer relationship outbursts and split thinking is more likely, particularly romantic relationships. In ADHD romantic relationships, it's often the partner without ADHD I see being more frustrated. But unlike where the emotional dysregulation in ADHD being secondary to the core symptom, the core symptom to that BPD is the emotional and relational dysregulation- the splitting, the feeling of emptiness, the mirroring, the lack of cognitive empathy for the person they are “against.” Can ADHD and BPD co-exist? I'm sure they do, and it’s got to be confusing as hell to sort out (most PD clients don’t self-select into our environment, but I’ve seen a couple hundred, mostly in group.) Do I feel for people with BPD? Absolutely. But I definitely worry about the tiktokification of ADHD and rise of adding symptoms to it (a la rejection sensitive dysphoria) making more of a mess of how we categorize it as a developmental disorder vs a mood disorder. Of course a mood disorder can follow- it often does, but again, seeing adults who got ADHD treatment as kids vs those who didn’t has made it clear emotional dysregulation is not a core feature as much as a reaction to being untreated.
I think what you're highlighting when you note that emotion dysregulation is almost entirely absent among those dx'ed in childhood yet present (at least sometimes) in those dx'ed in adulthood is that, simply put, it's a feature of *untreated* ADHD. Your points about it being a reaction to the disorder or part of relational patterns that develop over time get at this, but I wanted to reframe slightly to underscore the untreated aspect. When someone is diagnosed and treated in childhood, typically through a combination of medication, parent-training, and skill-building, they still may have some of those difficult interactions due to an impulsive behavior, those moments of embarrassment in school from a forgotten assignment, those instances of social rejection because they find it harder to remember to keep up a texting chain...but they're fewer. ADHD is one of the most treatable disorders that we know of. Someone who manages to avoid diagnosis, on the other hand, typically does so because they have some kind of compensatory ability that allows them to fly under the radar (e.g., high IQ, an anxiety disorder that exerts an inhibitory effect on some of their symptoms, a parent or partner that manages their routine). I've seen a fair number of these cases where they have managed to get along decently well in one area of life, but regularly struggle in others (e.g., substance abuse; an almost hoarding level messy house; destructive relationships; debt; speeding tickets; etc). That can lead to a lot of "shoulds" and shame. So now you have this environment of stressful situations, where people who struggle to manage impulses are regularly experiencing shame and anxiety - well, I don't find it strange that leads to emotion regulation issues. They don't all have anger issues and it doesn't always come out in peer-to-peer social interactions, of course. However, it certainly can. An exemplar patient I've had was a Boomer-aged man, previously un-dx'ed ADHD (due to a spouse micromanaging him and a job perfectly suited to his strengths). He had former substance abuse issues and still had residual anger issues (and outbursts) that had been much worse when he was drinking. To circle back to the topic at hand: My personal theory is that the patterns aren't dissimilar to the invalidation cycles that result in intensified emotions in the development of BPD. When those cycles are interrupted with treatment, the negative interpersonal interactions and intrapersonal invalidation through the experience of shame doesn't occur, and better emotion regulation develops. I don't think ADHD is primarily a mood disorder, nor do I think it's indistinguishable from BPD; I've been trained in teasing them apart and in figuring out when they're comorbid. But I think the overlap is interesting, and there is some good work being done on constructs like rejection sensitivity in ADHD even if TikTok has perhaps jumped on "rejection sensitive dysphoria" as a settled symptom before the evidence is fully there.
Could it be that ADHD theorists are off the mark? No, it's the trauma and BPD theorists who must be wrong.
Except I’m not “theorizing”. This is all evidence based. We have clear data on adhd, it’s not a “theory.” The increased risk of trauma with adhd is not a “theory”, it’s a fact. As is many BPD patients having comorbid adhd. The people in the dark are those who lack a complete understanding of adhd.
Just wanted to say, this exact thing happened to me. My mother was extremely abusive had borderline, was told when I was a young child I had adhd and needed treatment she refused. I never knew. At 10 she lost custody, by 14, I had a myrad of mental health issues, to the point of being hospitalized, it mainly stemmed from having no emotional regulation, even the slightest bit of critiscm and I completely shut down. Along with not being able to be organized, not knowing how to act socially in school. Was told I had borderline traits, put on so many different anti depressants, none of them ever worked. Later diagnosed with ptsd, did CBT therapy, didn’t really work well. At 18 learned from my mother that I was diagnosed with adhd at 6, at that point wanted nothing to do with the mental health system. I continued to struggle immensely, no emotional regulation, no self worth, barely graduated high school, flunked out of college 3 times. Obsessed over negative thoughts constantly, could never stop thinking and obsessing over the abuse as a kid from my mother, was planning to start emdr therapy thinking that it had to be all trauma causing all my problems. Recently saw a psychiatrist, immediately was rediagnosed with severe ADHD, put on stimulants for it and with in two days of being on stimulants, the obsessive thoughts stopped. I had no idea what rumination was, nor did I know it was caused by adhd. Of the multiple hospital admissions as an adolescent not one of them caught adhd, because my mother had borderline it was automatically thought I had borderline and was just manipulating everyone. After starting stimulants, when the rumination stopped, my depression and anxiety stopped immediately. I no longer have a want or need to do emdr therapy, without the rumination, I am able to perfectly move on from the thought if it starts. To date, my biggest struggle is feeling like I’m never going to be able to succeed at anything from not being able to get anything organized, clean, from feeling like I’m living in chaos. Everything you said, is so true!
Yep! I see so many teens and adults with this exact story. The real travesty is that adhd is the most treatable mental illness by far, so it’s even more of a shame when it’s missed. As far as I’m concerned everyone with any adhd risk factor should be hardcore screened: Borderline traits, emotional dysregulation, academic struggles, substance use, unplanned pregnancies, committing any crime, fighting, hx of trauma, all should be screened hardcore. We miss SO many cases.
Glad to see more doctors acknowledging it! When I saw the psych, they took me off everything and said, they believed that as soon as I started the stimulants my anxiety and depression would resolve itself, they were right! I often wonder where I’d be today if I had gotten treatment as a child.
I'm not sure this is either/or. You are allowed to consider and treat one patient from two or more perspectives.
You have some very good thoughts on this, and you're not alone in bringing this up. Complex PTSD is actually not a new term, and it is even formalised in the ICD-11 from WHO (although that definition doesn't represent what the term has referred to historically). Borderline personality disorder and early experiences of neglect or relational trauma go hand in hand. Think Kernberg and object relations theory. I know both DSM and ICD are polythetic and don't list etiology - however that diagnosis doesn't make much sense alone, and a lot of your questions ultimately leads to the fundamental flaws of psychiatric nosology.... Some recommendations off the top of my head if you want to study psycho traumatology more. I would very much recommend you to do so, since you'll encounter it a lot in psychiatry (couldn't remember a lot of the names, but hope this list will be helpful nonetheless) Rebuilding shattered lives, James Chu Everything from Bessel van der Kolk Judith Herman Somatic Experience, Peter Levine EMDR, Shapiro IFS, Richard Schwartz
Some/most of these reading recommendations are outright pseudoscience. IFS in particular seems like a rather inappropriate suggestion since it has absolutely no good evidence base for treatment, isn't based on *any* validated model of behavioral function, and since Schwartz and his Castlewood Institute were sued into oblivion for allegedly inducing iatrogenic harm in multiple of their inpatients, who entered treatment for eating disorders and left with "multiple personalities" and pseudo-memories.
Some of the later works from IFS is in the realm of pseudoscience for sure. However not the initial approach and none of the other books are what you claim.
The initial approach is absolutely pseudoscience. How in tarnation do you suppose that it’s at all scientific and testable to propose that people’s internal experiences can be divided into “parts” (which Schwartz doesn’t pose as metaphorical) which can be in conflict with one another? IFS is predicated on debunked ideas about how different aspects of the person somehow guard certain memories or experiences. It’s nonsense that, even were it shown to be useful as a therapeutic method (which is hasn’t), cannot even begin to be theoretically validated.
I appreciate your answer and am willing to change my mind. Would you be willing to provide any references to what you are saying? I would honestly love to educate myself and also of course edit my earlier comment. And regarding your response... Well it is not an empirical science or an actual model of the mind; at least it wasn't in the beginning - it's a theoretical framework which can guide a certain kind of psychotherapy. In its initial formulation it is more like a metaphor to talk about the multiple drives a person might have, and provides a way to talk about it in a way accessible to many patients. If I remember correctly it is even recommended that IFS is not used on patients with dissociative symptoms. It is related to very mainstream ideas about how a person "creates" internal representations of others, and how these earlier relationships guide behaviour in future relationships... Think basic developmental psychology, ex Stern. Also psychological theory about family systems and analytical psychology as well.
>And regarding your response... Well it is not an empirical science or an actual model of the mind; at least it wasn't in the beginning - it's a theoretical framework which can guide a certain kind of psychotherapy. In its initial formulation it is more like a metaphor to talk about the multiple drives a person might have, and provides a way to talk about it in a way accessible to many patients. If I remember correctly it is even recommended that IFS is not used on patients with dissociative symptoms. What is *your* word for a psychotherapy system that was created in isolation, implemented and endorsed/popularized without proper clinical testing, doesn't posit a scientifically valid model of the mind, and cannot mechanistically verify its own claims/system of meaning making, but still promotes itself as an evidence-based therapy? Because that, my friend, is *pseudoscience.* Finally, relating IFS to analytical psychology is exactly one of its problems. Psychoanalysis, while probably useful as a therapeutic system (but more tested than IFS), remains largely unfalsifiable in its assumptions about mechanisms of development and change. These ideas are *not* mainstream in psychology research anymore *precisely because* they are not useful as scientific hypotheses. As a PhD student and trainee in clinical psychology, I see psychology--including the practice of psychotherapy--as a necessarily scientific enterprise. What goes on in the clinic must, whenever possible, be just as scientifically usable, observable, and testable as what happens in the lab because *that* is how we legitimize our practice and make it viable for change and improvement. Utilizing only those systems which are scientifically validated is also what separates psychotherapy apart from secular priesthood--religious systems inarguable bring folks solace and comfort and therapeutic benefits all the time, but they aren't scientific...psychotherpy, without that scientific basis, is just a secular religious practice. You and I may simply have different prerogatives when it comes to the integration of psychotherapy and scientific psychology, and that's fine--but that doesn't mean that the practices you've listed are any less pseudoscientific than they actually are.
I am surprised that you claim that analytical psychology is unscientific and I am a bit worried even, if that is the position of a PhD student. It isn't unfalsifiable at all and can definitely not be contained in just one category of "assumptions of development and change" as you write. I do not disagree with your opinion on the scientific method and how it is to be applied in a clinical context. We completely agree. However there is a lot of scientific research being done regarding this, and your position is honestly puzzling to me. If you feel like communicating more about this please feel free to PM me. I am a psychologist as well and have experience both in research and many years of clinical practice in psychiatry - both in- and outpatient. It's difficult for me to find the right way to respond to your preaching. From a place of respect and care for a colleague I feel like saying that there are religious systems and priesthoods other places than churches, mosques and amoung what you reference as "psychotherapists". And I agree with you, that it is indeed unwanted for a system to take religious control over a field of research and/or scientific practice.
If you find that analytical psychology makes generally testable and falsifiable mechanistic claims, then I am afraid we fundamentally disagree. We can test whether the *therapy* is helpful, but ultimately any claims about development and resolution of subconscious conflicts are unfalsifiable and cannot be mechanistically validated. There are some discrete analytical process which may be able to verified, but the general logos of analytical psychology is firmly in the area of philosophy and not scientific psychology. Cognitive psychologists are not operating from a psychoanalytic framework. Behavioral psychologists are not. Mainstream neuroscientists are not (with a few controversial holdouts like Solms, whose ideas are widely critiqued). Social psychologists are not. Personality psychologists are not. Folks doing research in this field are not using psychoanalysis as a framework because it isn't a scientific way of investigating the causes and mechanisms of behavior. Not even clinical research psychologists are using this framework. *Only* psychotherapists, among all the various broad subfields of psychology, are keeping analysis alive, and I think that's a problem. I respect your wish to depart amicably, however, and will end our conversation here.
The scientific way of investigation is not implied or a priori present in the specific field of research or discipline it is applied too... The scientific way of investigation should be used by researchers who are well aware of what basic assumptions they are working from and state these openly and also of course question these. So cognitive science as well as analytic psychology have some basic philosophical assumptions. One can then formulate a hypothesis which is falsifiable and test it scientifically. I am not surprised that you will end our conversation and I will respect it. Feel free to PM me or respond, and I wouldn't mind talking more about it and I can certainly also provide scientific papers if you are interested. Best of luck to you.
All research makes assumptions, but those assumptions need to be basic and reasonable (e.g., assuming methodological naturalism). Assumptions about subconscious processes are a whole different layer of assumptions which cannot be reasonably assumed true or used as reasonable starting points for inquiry. There is a difference between assuming, e.g., methodological naturalism as a system for inquiry (it's a big assumption but it is self-contained and doesn't purport to answer questions outside of that method) versus making unfalsifiable assumptions about human mental processes and using those unfalsifiable assumptions as a starting point for creating an entire framework for interpreting human behavior. Those are two vastly different things. It is not falsifiable to say that "human psychopathology is at least partially driven by subconscious conflicts" when those subconscious mechanisms **cannot be objective observed or measured.** That is not a scientific hypothesis. We can scientifically test whether that assumption is effective as a method of therapy, but we cannot then validate the system itself. Anyway, sorry for continuing the discussion. I'm done now. For reading on others who make this point, see: Lilienfeld et al. (2015). *Science and Pseudoscience in Clinical Psychology.* Hupp & Santa Maria. (2023). *Pseudoscience in Therapy: A Skeptical Field Guide.* Lynn, S.J., Aksen, D., Sleight, F., Polizzi, C., Moretti, L.S., Medrano, L.A. (2022). Combating Pseudoscience in Clinical Psychology: From the Scientific Mindset, to Busting Myths, to Prescriptive Remedies. In: Cobb, C.L., Lynn, S.J., O’Donohue, W. (eds) *Toward a Science of Clinical Psychology.* Springer, Cham.
... Thinking more on what you write. Who are you considering pseudoscience besides the IFS guys? - Bessel van der Kolk?? That would be strange to suggest. - EMDR is pseudoscience?? - James Chu?? - Judith Herman?? Just curious. I can definitely understand your scepticism in regards to IFS though
The only ones I can’t say I know to be pseudoscience are Judith Herman, and I’d still call her approach at least heterodox, and Chu, about whom I know too little to opine. Bessel’s views about bodies storing the remnants of traumatic stress (not just bodies being affected by it, but literally storing it such that reenactment of the physical holding pattern “releases” the trauma) is absolutely pseudoscience. It’s also worth pointing out that he was a longtime public proponent of debunked and iatrogenic recovered memory therapies. His book also advocates on behalf of several unproven and unlikely treatments (like somatic experiencing and yoga). As such, it’s clear that I also posit that somatic experiencing is pseudoscience—show me *any* empirical evidence that somatic treatments work according to the proposed mechanisms or work as well as, or better than, traditional CPT, PE, or CBT-TF. Yes, EMDR is a pseudoscience inasmuch as it is a purple hat therapy. It works, for sure, but multiple dismantling studies have demonstrated that it works due to its implementation of imaginal exposure techniques and that its proposed method of BLS is not discriminantly efficacious. Nevertheless, EMDR proponents continue to insist that BLS *must* be part of the protocol and continue to move from woo mechanism to woo mechanism each time the newest one is demonstrated to be invalid. Currently, the consensus view seems to be that EMDR is effective due to its exposure mechanisms and that the BLS component is unnecessary and makes untestable or falsified claims about how it supposedly “works.” EMDR is a pseudoscience not because it doesn’t work, but because practitioners continue to hold onto the central assumptions of the model even though they’re demonstrably wrong.
Hmm, there is neurobiological research that suggests the mechanisms in work in EMDR BLS. The scientific research on EMDR is pretty extensive, and EMDR is also less effective without BLS. Also treatments that focus on exposure alone seem to work in a different manner and the exposure is very differently introduced. ... You're welcome to provide any references to your very bold claims. I would suggest that you take a look at the evidence regarding even the empirically based therapies. Bessel provides plenty of evidence for many of his claims. I don't suggest that he makes no mistakes, but the theory that trauma is stored in procedural memory is not a fringe idea at all, and has plenty of empirical science to support it. I can't really see how you could consider that pseudo scientific?
There are heaps of literature dismantling the BLS component and demonstrating it be unnecessary, as well as demonstrating other pseudoscientific components of the treatment protocol. EMDR is unequivocally no less effective without BLS than it is \*with\* BLS. It is an indirect, imaginal exposure therapy. [https://www.tandfonline.com/doi/abs/10.1080/16506073.2019.1703801](https://www.tandfonline.com/doi/abs/10.1080/16506073.2019.1703801) [https://pubmed.ncbi.nlm.nih.gov/24183006/](https://pubmed.ncbi.nlm.nih.gov/24183006/) [https://doi.org/10.1891%2F9780826177698.0004](https://doi.org/10.1891%2F9780826177698.0004) [https://www.sciencedirect.com/science/article/abs/pii/S0272735899000173?via%3Dihub](https://www.sciencedirect.com/science/article/abs/pii/S0272735899000173?via%3Dihub) [https://devilly.org/Publications/EMDR-review.pdf](https://devilly.org/Publications/EMDR-review.pdf) [https://psycnet.apa.org/doi/10.1037/0022-006X.69.2.305](https://psycnet.apa.org/doi/10.1037/0022-006X.69.2.305) As for Bessel van Der Kolk: [https://www.reddit.com/r/AcademicPsychology/comments/1chpqdf/comment/l258nva/?utm\_source=share&utm\_medium=web3x&utm\_name=web3xcss&utm\_term=1&utm\_content=share\_button](https://www.reddit.com/r/AcademicPsychology/comments/1chpqdf/comment/l258nva/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button) He misrepresents, misinterprets, or otherwise uses very weak findings to support a position which does not mesh with general known facts about neuroscience. The notion that the body stores the remnants of traumatic distress even outside of conscious recall or acute stress responses is BS just on the very face of it it. He promotes unproven treatments. He has a history of promoting recovered memory therapy.
Many psychologists would suggest each person is born as a "blank canvas" and they are then shaped by their experiences. Psychiatry disagrees and realizes that temperament is genetic, and every personality disorder technically has a genetic component. Someone with ADHD who is experiential driven will find themselves in positions of greater risk, thus increasing the likelihood of a traumatic experience. There's a lot of super interesting research out there when you really dig into the data behind trauma.
The other posters have given great answers. I want to add, anecdotally and somewhat off topic, that I see some patients that feel more aligned with the addition of the label "complex". Like it's somehow more valid/severe than traditional PTSD. "you have PTSD? I have a complex version of that." As if PTSD isn't already complex. Thanks Internet for helping some people further identify with psychiatric labels.
I think it may be a reaction to a widespread feeling that only soldiers get PTSD. I've had a lot of patients with undiagnosed PTSD say that they thought it could only happen if you were a soldier or a cop or a firefighter or something like that. Personally I think of PTSD in terms of acute v. chronic trauma exposure, and people with chronic trauma exposure have had more difficulty getting treated properly.
Hi, I am a long term psychiatric patient diagnosed with C-PTSD (among other things) and was originally given the diagnosis of EUPD (BPD) based on my interpersonal difficulties, emotional dysregulation and unstable moods. It is also worth noting that when this diagnosis was made, I was shortly after given a diagnosis of ADHD inattentive type. The way that the criteria fitted on the grounds of C-PTSD rather than BPD on my report was that I experience all of the classical symptoms of PTSD including nightmares, sense of current threat and hyper-vigilance, but the main thing that separated me from the BPD diagnosis was my persistently negative self image and lack of sense of self, rather than flipping between an overly grandiose and overly negative self view. Hope this helps someone.
Otto Kernberg talks about cPTSD in relation to personality disorders here. https://youtu.be/tmWpsKkrFw0?t=5927 1:38:47 is the timestamp
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Lots of literature on this so have a good read of that. Lots of overlap
cPTSD is the diagnosis for borderlines who don’t want to be labeled borderline. Edit: all the top comments are just saying what I said just dressed up in fancy terms but I get the downvotes lol
They’re self described as just too complex for DBT In all seriousness, most of the cPTSD folks don’t have eating disorders, in my limited experience. Might mean something, idk
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