Article Multiple and interpersonal trauma are risk factors for both post-traumatic stress disorder and borderline personality disorder: a systematic review on the traumatic backgrounds and clinical characteristics of comorbid post-traumatic stress disorder/borderline personality disorder groups versus single-disorder groups. Child Abuse Negl. 2017;31(4):50321.

Borderline personality disorder and related constructs as risk factors for intimate partner violence perpetration. J Trauma Dissociation. Borderline personality disorder and violence toward self and others: a National Study. Ziobrowski HN, Buka SL, Austin SB, Sullivan AJ, Horton NJ, Simone M, et al. Article In nationally representative samples in the United States, 2530% of adults meeting criteria for either PTSD or BPD also met criteria for the other disorder, and 3070% of adults diagnosed with BPD had an episode of PTSD at some point in their lifetime [50]. In a study with adult mental health patients, psychoform (but not somatoform) dissociation partially mediated the relationship between a history of childhood maltreatment and cPTSD (assessed using DESNOS criteria) [176]; importantly, this mediation occurred independent of the effects of BPD symptoms, fears of abandonment and closeness, and emotion dysregulation [180]. 2018;206(4):2706. 2009;171(1):4453. Although dissociative symptoms are highly correlated with PTSD symptom severity among adults decades after experiencing childhood sexual abuse [123], pathological dissociation was not included in the PTSD diagnosis until the DSM-5 revision identified a dissociative sub-type of PTSD (PTSD/D) [100, 101]. Van Dijke A, Ford JD, Van der Hart O, Van Son M, van der Heijden P, Bhring M. Complex posttraumatic stress disorder in patients with borderline personality disorder and somatoform disorders. The course of improvement during a stage-based treatment for suicidal and self-injuring women with borderline personality disorder and PTSD. More specific implications for clinical practice and research now will be discussed. Treatment of complex traumatic stress disorders in adults. Biol Psychiatry. Additional research is needed across a range of different clinical and general population samples to determine whether BPD or specific BPD symptoms can be consistently distinguished from cPTSD and its symptoms. Flight responses involve active attempts to restore safety by disengaging from sources of harm (e.g., fear of closeness) and distress, which are highly self-referential (i.e., associated with the DMN) and include attempts to mobilize executive problem solving and decision-making (i.e., associated with the PfC). Roth S, Newman E, Pelcovitz D, vander Kolk B, Mandel FS. 1994;59(2-3):22849 Retrieved from Article Cassidy J. Emotion regulation: influences of attachment relationships. van der Kolk B, Ford JD, Spinazzola J. Comorbidity of developmental trauma disorder (DTD) and post-traumatic stress disorder: findings from the DTD field trial. J Abnorm Psychol. Perkonigg A, Hofler M, Cloitre M, Wittchen HU, Trautmann S, Maercker A. Acta Psychiatr Scand. Herman JL. 2017;18(4):52243. Psychiatry Res Neuroimaging. Borderline Pers Disord Emot Dysregul. Lanius RA, Rabellino D, Boyd JE, Harricharan S, Frewen PA, McKinnon MC. For example, a study with pre-school age children, including both victims of sexual abuse and a non-abused comparison group, found that sexually abused childrens self-reported attachment disorganization and parent-observed emotion dysregulation were strongly inter-related, more severe than for the non-abused children, and mediated the relationship between sexual abuse and parent-observed dissociation 1year later [67]. Distinguishing PTSD, complex PTSD, and borderline personality disorder: a latent class analysis. Miljkovitch R, Deborde AS, Bernier A, Corcos M, Speranza M, Pham-Scottez A. Borderline personality disorder in adolescence as a generalization of disorganized attachment. Lasting personality pathology following exposure to severe trauma in adulthood: retrospective cohort study. J Nerv Ment Dis.


BPD and PTSD are distinct regarding the precise qualitative definitions of their diagnostic features but have been found to have substantial potential overlap in their symptom criteria. 2019:121. Emotion regulation processes and Psychoform and somatoform dissociation in adolescents and Young adults with cumulative maltreatment. Psychol Trauma Theory Res Pract Policy. Greene T, Neria Y, Gross R. Prevalence, detection and correlates of PTSD in the primary care setting: a systematic review. Evidence for two different ICD-11 posttraumatic stress disorders in a community sample of adolescents and young adults. While preliminary, taken together these findings suggest that emotion and relational dysregulation in BPD may involve brain alterations associated with unstable and ruminative self-awareness, fear of abandonment, inability to recover from intense negative affect, and, in some cases, alternating hyperalgesia and dissociative analgesia. Relation between childhood maltreatment and severe intrafamilial male-perpetrated physical violence in Chinese community: the mediating role of borderline and antisocial personality disorder features. 2013;5(3):21724. The comorbidity of cPTSD and BPD was reported for the DESNOS version of cPTSD in a Dutch inpatient psychiatric sample [180]: BPD was comorbid in 79% of cPTSD cases and cPTSD was comorbid in 40.5% of BPD cases. In PTSD, pain-related impairment due to hyperalgesia rather than analgesia also is prominent [7, 38, 141]. By contrast, the DSO symptoms of cPTSD are consistent with the flight response, which is characterized by both unmodulated distress (i.e., DSOs difficulty in self-calming, guilt, and sense of worthlessness) and both conscious and unconscious attempts to escape from further harm (i.e., DSOs emotional numbing and relational detachment). Whether similar structural brain abnormalities characterize cPTSD is not yet known. 2017;8(1):1344080. Annual Research Review: Enduring neurobiological effects of childhood abuse and neglect. When disorganized attachment persists into adulthood, emotion dysregulation consistent with cPTSD (e.g., withdrawal, rumination, inability to self-calm) and with BPD (e.g., desire for retribution, instability, hostility) has been shown to be more severe than for adults with secure, anxious, or avoidant attachment working models [53]. Although a combination of emotional abuse with sexual or physical abuse has been found to be particularly strongly associated with severe childhood psychosocial problems in clinical samples, emotionally abused children and adolescents also have a profile of behavioral and emotional problems distinct from the symptom profile associated with sexual or physical abuse [159]. Bracha HS. Frias A, Palma C. Comorbidity between post-traumatic stress disorder and borderline personality disorder: a review. dissociation Thus, the three most extensively tested approaches to PTSD psychotherapy (EX, CT, and EMDR) have been systematically integrated with DBT. JAMA Psychiatry. American Psychiatric Association. The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Pain Med. J Neurosci Res. 2017;14:10915. The comorbid BPD/cPTSD sub-group members were more likely to report a history of childhood physical, sexual, and emotional abuse and neglect than the PTSD or low symptom sub-group members. 2016;16:180. Negative urgency accounts for the association between borderline personality features and intimate partner violence in Young men. In earlier versions of the DSM and the ICD (i.e., DSM-IV and ICD-10, PTSD symptoms (i.e., dissociative amnesia and flashbacks; emotional numbing; anger) are similar to BPD features of transient dissociation, chronic emptiness, and intense anger. Moore KE, Gobin RL, McCauley HL, Kao CW, Anthony SM, Kubiak S, et al. statement and Doering S. Borderline personality disorder in patients with medical illness: a review of assessment, prevalence, and treatment options. 2020;107:104574.

cPTSD was originally defined as a disorder of extreme stress not otherwise specified (DESNOS) following traumatic victimization with symptoms in seven domains: emotion dysregulation, altered schemas of self, altered relationships, trauma-related sustaining beliefs (morality, spirituality), somatization, and altered perceptions of perpetrators [142]. 2016. Mil Med. Psychol Psychother. A fifth sub-groups members infrequently endorsed any symptoms (20%).

Eur J Psychotraumatol. Thus, DTD includes symptoms that closely parallel most of the symptoms of adult BPD and cPTSD/DSO as well as symptoms that are developmentally specific to childhood and related to childrens adaptations to traumatic victimization and disrupted attachment bonding [25] that could be precursors of adult cPTSD or BPD. Trauma Violence Abuse. Lyons-Ruth K, Bureau JF, Holmes B, Easterbrooks A, Brooks NH. Hyland P, Vallieres F, Cloitre M, Ben-Ezra M, Karatzias T, Olff M, et al. Psychosom Med. 2020;28(4):23854. [153], raising the question of whether the deficits in amygdala inhibition and emotion regulation are associated with cPTSD/DSO rather than, or in addition to, BPD or PTSD per se. Deficient amygdala habituation to threatening stimuli in borderline personality disorder relates to adverse childhood experiences. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. 2019;32(6):87780. DBT-PTSD supplemented standard DBT with two variants of PTSD trauma memory processing (Cognitive Therapy and PE), Compassion Focused Therapy [193], and Acceptance and Commitment Therapy [139]. Both a history of childhood interpersonal trauma and current dissociative symptomsspecifically neurological conversion symptomswere found to be associated with cortical activation patterns characteristic of emotion dysregulation (i.e., frontal EEG asymmetry) among adults in treatment for BPD when they were exposed to aversive pictures [134]. Affect dysregulation, adult attachment problems, and dissociation mediate the relationship between childhood trauma and borderline personality disorder symptoms in adulthood. PubMed 2nd ed. Lyons-Ruth K, Spielman E. Disorganized infant attachment strategies and helpless-fearful profiles of parenting: integrating attachment research with clinical intervention. Adults in mental health treatment were found to display two different types of disorganized attachment: a highly emotionally labile group whose members had the most severe BPD symptoms, and an emotionally detached group whose members had the most severe avoidant and schizoid symptoms (although trauma history and PTSD symptoms were not assessed in that study) [5]. Based on these findings, PTSD and BPD appear distinct with regard to dissociation (i.e., transient reactions to extreme interpersonal distress in BPD versus chronic adaptation to fear related to poly-victimization in PTSD), except for possible overlap in some cases in which PTSD/D and BPD co-occur [189]. A systematic review. Thus, disorganized attachment may be associated with BPD or cPTSD or both, and more specifically, with the severe emotion dysregulation found in these disorders. Moreover, despite evidence of reduced suicidality, self-harm, and depression, and improved psychosocial functioning, the observed benefits were less than those required by MIREDIF. PubMed With the many unanswered questions about the role and type of trauma exposure in the etiology of BPD, cPTSD, and PTSD, psychobiological studies exploring commonalities and distinguishing features of the disorders are particularly important. Emotional dysregulation and attachment dimensions in female patients with bulimia nervosa. J Personal Disord. In cPTSD, emotion dysregulation is characterized by trauma-related self-perceptions (e.g., guilt, shame, helplessness), fear of closeness in relationships, and numbing or suppression of emotional expression [88]. Thomaes K, Dorrepaal E, Draijer N, de Ruiter MB, Elzinga BM, Sjoerds Z, et al. CAS Scalabrini A, Cavicchioli M, Fossati A, Maffei C. The extent of dissociation in borderline personality disorder: a meta-analytic review. Beeney JE, Wright AGC, Stepp SD, Hallquist MN, Lazarus SA, Beeney JRS, et al. Relatedly, a meta-analysis of neuroimaging studies testing reactions to affective stimuli that were negatively-valenced versus ones that were neutral found that BPD was associated with hyperactivation of limbic (i.e., amygdala and hippocampus), posterior cingulate, temporal cortical, and medial PfC areas and hypoactivation of the postcentral gyrus [153]. 2017;73(4):43948. Emotional abuse and neglect were particularly prevalent, with BPD associated with more than 30 times increased likelihood of the former and more than 20 times increased risk of the latter, as compared to non-clinical adult samples [136]. Attachment disorganization [15, 115, 119] and emotion dysregulation [68, 69, 119, 188] both have been shown to be related to pathological dissociation. Monogr Soc Res Child Dev. Krause-Utz A, Mertens LJ, Renn JB, Lucke P, Wohlke AZ, van Schie CC, et al. Chronic pain types differ in their reported prevalence of post -traumatic stress disorder (PTSD) and there is consistent evidence that chronic pain is associated with PTSD: an evidence-based structured systematic review. A 10-year follow-up of adults diagnosed with BPD found that most (85%) who had been initially diagnosed with PTSD were in remission from PTSD but continued to meet criteria for BPD [192]. 2015;172:42844. Based on confirmatory factor analysis studies with adults [12], the ICD-11 diagnosis of cPTSD is defined operationally as requiring one of the two symptoms from each of three DSM-IV criteria for PTSD (i.e., intrusive re-experiencing, avoidance of trauma reminders, hyperarousal) and one of the two symptoms from each of three domains of Disturbances of Self-Organization (DSO). An on-line education program for therapists and their DD-diagnosed patients has been adapted from the TOPDD study findings, providing a basis for both clinicians and clinical researchers to incorporate the treatment guide in clinical practice and clinical trials research with patients with BPD and severe dissociation. New York: Guilford; 2020. p. 99124. The dissociative subtype of PTSD: a replication and extension. Chung BY, Hensel S, Schmidinger I, Bekrater-Bodmann R, Flor H. Dissociation proneness and pain hyposensitivity in current and remitted borderline personality disorder. 2017;(sup5):1353383. Although the clinical phenomenology of emotion dysregulation differs for cPTSD and BPD, emotion dysregulation appears likely to be a link between childhood maltreatment adult symptoms and impairment in both cPTSD and BPD. Moreover, the revised PTSD criteria in the DSM-5 [3] include new symptoms of pervasive negative changes in cognition, mood, and behavior that parallel other BPD criteria (i.e., identity disturbance, interpersonal mistrust, dysphoric affective instability, impulsivity, self-harm) [148]. Although both cPTSD and BPD involve severe relational problems, this involves intense volatile relational hostility and alternating enmeshment and disengagement to avoid real or imagined abandonment in BPD. Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians. Childhood poly-victimization (i.e., four or more types of maltreatment) also has been found to be associated with both cPTSD alone and comorbid cPTSD/BPD [52]. Dissociation thus was not included in subsequent structural analysis studies of the symptoms selected for the ICD-11 version of cPTSD ([12], p. 9). Krause-Utz A, Winter D, Niedtfeld I, Schmahl C. The latest neuroimaging findings in borderline personality disorder. Childhood sexual abuse has consistently been found to be a risk factor for BPD, and both childhood and adult sexual abuse and assault are associated with the most severe, lethal (e.g., self-harm), debilitating (e.g., dissociation), and chronic BPD symptoms [173] as well as with comorbid PTSD [27]. 2014;16(2):434. However, deficits in both inhibition and regulation of hyperactivation by the amygdala and of heightened states of negative emotion have been linked specifically to BPD in the context of a history of childhood adversity [8]. In cPTSD/DSO, relational dysregulation instead is characterized by avoidance and detachment based a fear of closeness [18]. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. J Personal Disord. Christine Courtois has no competing interests. In light of the impairment experienced due to dissociation by many patients diagnosed with BPD and cPTSD, the incorporation of therapeutic approaches to the treatment of dissociative disorders (DD) also warrants consideration [161]. J Personal Disord. Harv Rev Psychiatry. Volchan E, Souza GG, Franklin CM, Norte CE, Rocha-Rego V, Oliveira JM, et al. 2019;118:8397. Psychiatry Res. In the relational domain, DTD has symptoms similar to cPTSDs detachment and avoidance and BPDs attachment disorganization, defensive aggression, relational enmeshment, and deficits in empathy and relational boundaries (the latter including boundary violations in an attempt to avoid abandonment, as well as excessively impermeable boundaries) but also excessive empathy, which is found in neither BPD nor cPTSD. 2019;359:18. 2019;19(1):3.

In BPD, deficits in interpersonal trust, tolerance of aloneness, and recognition of conventional norms of social cooperation/fairness also have been documented and shown to be associated with altered patterns of anterior cingulate, temporal lobe, and insula activation [97, 149]. Hyland P, Karatzias T, Shevlin M, Cloitre M. Examining the discriminant validity of complex posttraumatic stress disorder and borderline personality disorder symptoms: results from a United Kingdom population sample. 2006;20(1):915. Del Rio-Casanova L, Gonzalez A, Paramo M, Van Dijke A, Brenlla J. Emotion regulation strategies in trauma-related disorders: pathways linking neurobiology and clinical manifestations. Acta Psychiatr Scand. In a sample of outpatient treatment-seeking women with childhood abuse histories [19], three sub-groups were identified that were characterized by: (1) PTSD with minimal DSO and BPD symptoms except for interpersonal detachment; (2) cPTSD with both PTSD and DSO symptoms and minimal BPD symptoms except emotional emptiness; and (3) BPD plus all PTSD and DSO symptoms except for avoidance. Validation of post-traumatic stress disorder (PTSD) and complex PTSD using the international trauma questionnaire. The emerging findings from person-centered research suggest that PTSD and DSO often occur in the absence of BPD symptoms, but that BPD often occurs with comorbid PTSD and DSO symptoms than alone. Shame, dissociation, and complex PTSD symptoms in traumatized psychiatric and control groups: direct and indirect associations with relationship distress. Understanding interpersonal trauma in children: why we need a developmentally appropriate trauma diagnosis. Prospective longitudinal research with repeated assessments of the disorders symptoms across critical developmental periods and transitions across the lifespan would be necessary to determine whether, and under what conditions, there is temporal sequencing in the onset and progression of the disorders. J Affect Disord. 2018;9:1962. Attachment insecurity in infancy has been shown to be predictive of emotion regulation decades later in adulthood [55]. Neuroimage Clin. 1950;1(4667):138392. Fossati A, Gratz KL, Somma A, Maffei C, Borroni S. The mediating role of emotion Dysregulation in the relations between childhood trauma history and adult attachment and borderline personality disorder features: a study of Italian nonclinical participants. Harned MS, Gallop RJ, Valenstein-Mah HR. A growth curve analysis of emotion dysregulation as a mediator for violence in individuals with and without borderline personality disorder. Abnormalities in functional connectivity in borderline personality disorder: correlations with metacognition and emotion dysregulation. 2015;3(2):21529. 2013;206(23):27381. Consistent with that finding, childhood sexual abuse was shown to be the one type of adverse childhood experience that was strongly directly associated with both BPD and PTSD among adults in inpatient psychiatric treatment [11]. Support for writing of the paper was provided by a grant from the Substance Abuse and Mental Health Services Administration, Center for the Treatment of Developmental Trauma Disorders (5U79SM080013, J. Ford, Principal Investigator). Breuer F, Greggersen W, Kahl KG, Schweiger U, Westermair AL. J Trauma Dissociation. Am J Psychother. Google Scholar. Complex PTSD - a better description for borderline personality disorder? Girme YU, Jones RE, Fleck C, Simpson JA, Overall NC. The potential role of cPTSD also should be considered when emotion dysregulation attributed to BPD involves distress related to a generalized sense of physical or emotional threat or betrayal, instead of (or in addition to) a terror of real or perceived abandonment or interpersonal rejection. Winter D. Attention to emotional stimuli in borderline personality disorder - a review of the influence of dissociation, self-reference, and psychotherapeutic interventions. Biol Psychol. Although both DESNOS and BPD have been found to be associated with a hippocampally-mediated bias toward memory encoding of negative (vs. positive) information [169], in cPTSD there is evidence of heightened dorsolateral and ventromedial PfC and anterior cingulate activation in reaction to negatively valenced emotional stimuli [71, 168]. Gardner AA, Zimmer-Gembeck MJ, Campbell SM. 2020;93(3):47489. Young adults from a non-clinical but lifetime adversity sample who engaged in interactions with a parent in a manner consistent with disorganized attachment were found to be likely than peers to have BPD symptoms and to engage in non-suicidal self-harm, although this was unrelated to their child abuse histories [109]. Courtois CA, Ford JD, Cloitre M, Schnyder U. Lyons-Ruth K, Pechtel P, Yoon SA, Anderson CM, Teicher MH. The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. Vogt KS, Norman P. Is mentalization-based therapy effective in treating the symptoms of borderline personality disorder? Dorahy MJ, Corry M, Black R, Matheson L, Coles H, Curran D, et al. Depress Anxiety. Horowitz M. Stress response syndromes: a review of posttraumatic and adjustment disorders. Evidence for default mode network dysfunction in borderline personality disorder. 2020;267:2208. 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