PTSD or BPD: How Can We Tell?

Written by: Graze Xu

Borderline Personality Disorder (BPD) and Post-Traumatic Stress Disorder (PTSD) are two distinct mental health conditions with different symptoms and causes, but they could show up very similarly. How can we tell their differences?

Let's first find out how they are similar. Some of the overlapping symptoms that may be present in both conditions include:

1. Intense emotional reactions: Both BPD and PTSD can involve difficulty regulating emotions, which can lead to intense rapid mood swings, impulsivity, and self-destructive behaviors. Individuals with BPD and PTSD may experience intense fear or anxiety in response to triggers that remind them of past traumatic events (American Psychiatric Association, 2013).

2. Impulsive behavior: Both conditions can involve impulsive behaviors. Individuals with BPD may engage in impulsive behaviors such as substance abuse, bing eating, or self-harm, while those with PTSD may engage in reckless or impulsive behavior as a way of numbing emotional pain (Cloitre et al.,2013)

3. High levels of distress and psychological suffering: Individuals with BPD may experience intense feelings of emptiness, shame, and self-loathing, while those with PTSD may experience intense fear, guilt, and anger (Cloitre et al.,2013). These emotional experiences can be difficult to manage and may lead to further impairment in daily functioning.

4. Both disorders have been associated with alterations in brain function and structure, particularly in areas involved in emotional regulation, such as the amygdala, pre-frontal cortex, and hippocampus (Ruocco, 2018; Bremner, 2006).

5. In addition to the similarities in symptomatology, BPD and PTSD also share some common risk factors, such as childhood abuse or neglect, chronic interpersonal trauma, and emotional dysregulation (Zanarini, Frankenburg, Reich, Fitzmaurice, & Weinberg, 2012).

You may wonder: Can one person have both?

Yes, research has suggested that the co-occurrence of BPD and PTSD is particularly common among individuals with a history of childhood abuse or neglect (Golier et al.,2003; Zanarini et al., 1999). The co-morbidity rate of BPD and PTSD varies depending on the population studied and the assessment methods used, but estimates generally range from 30% to 60% (Pagura et al., 2010; Zanarini et al., 1999).

Now we could see that differentiating between BPD and PTSD can be challenging, but there are some subtle differences that can help tell the differences:

1. Nature of trauma: While individuals with PTSD have typically experienced a single or multiple traumatic events, individuals with BPD may have experienced chronic or repeated interpersonal trauma, such as physical or sexual abuse, neglect, or emotional invalidation, which can contribute to their difficulties in interpersonal relationships (Zanarini et al., 2012).

2. Focus of the symtoms: BPD symptoms are primarily focused on the self and interpersonal relationships, whereas PTSD symptoms are focused on the traumatic event (Cloitre et al., 2013). For example, individuals with BPD may struggle with a persistent fear of abandonment and have difficulty maintaining relationships, while individuals with PTSD may experience flashbacks and nightmares related to the traumatic event.

3. Self-harm and suicidal behavior: While both BPD and PTSD may involve self-destructive behaviors, such as substance abuse or reckless driving, self-harm and suicidal behavior are more common in people with BPD, and individuals with PTSD may be at a higher risk of suicidal thoughts and behaviors due to the intensity of their symptoms (American Psychiatric Association, 2013).

4. Timeframe: While both BPD and PTSD may involve a history of trauma, BPD is considered a personality disorder that typically develops in adolescence or early adulthood and is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and emotions. In contrast, PTSD is a reaction to a traumatic event and can occur at any age (American Psychiatric Association, 2013).

5. Impact of functioning: BPD may be associated with more chronic and pervasive difficulties in daily life, whereas PTSD symptoms may be more episodic in nature (Harned et al., 2010).

6. Dissociative symptoms: such as depersonalization or derealization, are common in individuals with PTSD but are less frequently observed in individuals with BPD (Bremner et al., 1992; Paris, 2010).

7. Comorbidity: individuals with with BPD are more likely to have comorbid substance use disorders and eating disorders, whereas individuals with PTSD are more likely to have comorbid depressive disorders (Zanarini et al., 2012).

8. Severity and chronicity: BPD symptoms are often chronic and pervasive, whereas PTSD symptoms may be more episodic or time-limited (American Psychiatric Association, 2013).

9. Trauma-related beliefs: individuals with BPD may have more negative beliefs about themselves, such as feeling unlovable, worthless, or inadequate, as well as more negative beliefs about others, such as feeling that others are unreliable or abusive (Zanarini et al., 2018). On the other hand, individuals with PTSD may have more trauma-specific beliefs, such as feeling that the world is unsafe or that they are unable to protect themselves or their loved ones from harm (Resick et al., 2012).

10. Social interaction: while they can both have impact on interpersonal relationships, individuals with BPD may experience difficulties in maintaining stable relationships and may exhibit intense and unstable interpersonal behaviors, such as idealization and devaluation of others, fear of abandonment, and impulsivity, while people with PTSD may struggle with social interactions due to avoidance and feelings of detachment and estrangement from others (American Psychiatric Association, 2013).

11. Self-image: individuals with BPD may have a pervasive and unstable sense of self, which can manifest as identity disturbance and feelings of emptiness, while individuals with PTSD may experience a negative self-image related to the traumatic event, such as feeling guilty or responsible for the trauma or feeling ashamed of their reactions to the trauma (American Psychiatric Association, 2013).

12. Prevalence: BPD is estimated to affect approximately 1.6% of adults in the United States (Grant et al.,2008), although estimates vary widely depending on the population studied and the diagnostic criteria used (Trull et al., 2010) PTSD on the other hand, is estimated to affect approximately 3.5% of adults in the United States (Kilpatrick et al., 2013). BPD is more commonly diagnosed in women than men, with female-to-male ratio of approximately 3:1, while PTSD is also more commonly diagnosed in women than in men, with a female-to-male ratio of approximately 2:1 (American Psychiatric Association, 2013).

13. Treatment: it is important to consider the treatment implications of each disorder. Effective treatments for BPD typically involve long-term psychotherapy, such as dialectical behavior therapy (DBT), whereas PTSD is often treated with trauma-focused therapies, such as cognitive processing therapy (CPT) or prolonged exposure therapy (PE) (Cloitre et al., 2013).

Who is not interested in the treatment? As a new clinician, who completed the aforementioned PE and CPT certification, I actually could not agree to using PE to treat any trauma-related issues despite it having good evidence base and research that were funded. I believe more gentle and compassionate approaches need to be utilized towards any disorder that has its roots from trauma. Reviews by Acarturk et al. (2015), Powers et al., (2010), and Foa and McLean (2016), all raised concerns about the potential for distressing side effects in some individuals who received the treatment of PE, such as worsening of PTSD symptoms, dissociation, or emotional numbing. Schottenbauer, Glass, Arnkoff, and Gray (2008) conducted a meta-analysis of studies on PE therapy for PTSD and found that dropout rates were high, with up to 30% of participants discontinuing treatment prematurely.

I personally would wholeheartedly support more holistic and compassionate approaches. Examples would be what Bessel van der Kolk, MD. (2014) has outlined in his well-known book, The Body Keeps The Scores, such as Internal Family System (IFS), EMDR, Yoga, Neurofeedback, Sensorimotor therapy, Psychotics, and other Mindfulness-based interventions, which all should be applied cautiously with qualified trained professionals.

Dr. Jerad Lau, my professor from the University of Nevada, Las Vegas, pointed out that people with personality disorders rely heavily on a small number of dominant personality traits rather than having a wide range of non-dominant traits that could be used in various contexts equally. His theory about traits supports my approach to trauma, which is Parts Work. The most known Parts Work was the aforementioned IFS, founded by Dr. Richard Schwartz in the 1980's. I also believe it has its roots all the way back from the most renowned Gestalt therapy, founded by Dr. Fritz Perls in the 1940's. The reason that Parts Work could be so effective is that it offers the most compassion and understanding event to the client's most flawed parts of themselves, through healing, thus fosters the utmost self-compassion. Rost et al., (2019) conducted a randomized controlled trial comparing IFS to PE for the treatment of PTSD. One of their findings was that IFS therapy was associated with greater improvements in self-compassion and emotion regulation skills. Instead of enabling internal conflicts and power struggles, which could be the result of other behavioral-based approaches, Parts Work aims to gently heal the flawed dominate parts and build internal connections, understanding, and support between the parts of a client.

The kind of Parts Work that I am currently certified in is called Parts and Memory, founded by Dr. Jay Noricks of Las Vegas. It includes another research-based intervention, Memory Reconsolidation, from the field of Neuroscience. A simple illustration of this concept is when Harry Potter and Sirius Black were about to perish and he believed his deceased father had saved them, but it was actually his future self who traveled back in time and did so (Harry Potter and the Prisoner of Azkaban, 2004). If you're interested in learning more about this innovative approach, do let us know.

References:

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