PTSD & Co-Occurring Borderline Personality Disorder

At first glance, posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) may not seem to have much in common:

• PTSD is a mental health concern that can cause significant distress in the aftermath of one or more traumatic experiences.
• BPD is a personality disorder that is characterized by emotional impulsivity and a pattern of unstable relationships.

But when you look a bit closer, you may be surprised to discover that these two disorders are closely related. For example, many people who develop one of these conditions eventually receive a dual diagnosis of PTSD and borderline personality disorder:

• Among people who have PTSD, 24.2% also receive a diagnosis of BPD.
• Among people who have BPD, 30.2% are also diagnosed with PTSD.

In other words, nearly one in four people with PTSD also have borderline personality disorder, and nearly one in three people with BPD also have posttraumatic stress disorder.

One reason for the close relationship between BPD and PTSD may be that both conditions are associated with traumatic experiences. However, this is far from a universally agreed-upon assessment among mental health professionals. To explore this matter further, we should first take a brief detour through the history of BPD.

A Brief History of Borderline Personality Disorder

Among mental health professionals, the term “borderline personality” dates to at least the late 1930s, when American psychoanalyst Adolph Stern used it in reference to patients who “fit frankly neither into the psychotic nor into the psychoneurotic group.”

Through the decades, mental health professionals used variations of the term, including borderline states and borderline personality organization, as they attempted to accurately describe patients who had symptoms such as mood swings, fear of abandonment, unstable self-image, and a tendency toward impulsivity.

But BPD didn’t appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until the third edition of the standard reference book was published in 1980. Most sources credit the work of psychiatrist John Gunderson in the 1970s with helping BPD attain “official” status as a recognized disorder in the DSM.

In 1975, Gunderson published a seminal report on borderline personality disorder. In this paper, he established the following six key characteristics of borderline personality disorder:

1. Intense hostile or depressive emotions
2. Impulsive behaviors
3. Brief psychotic experiences
4. Chaotic relationships
5. Illogical thinking
6. Ability to uphold an outward appearance of normalcy

Gunderson would go on to publish more than 200 papers and 12 books on BPD and related topics. He also played an influential role in revising the clinical criteria for BPD and other personality disorders in subsequent editions of the DSM.

However, even with Gunderson’s significant contributions – and even though the disorder has been in the DSM and its global counterpart, the International Classification of Diseases (ICD), for several decades – borderline personality disorder remains a somewhat controversial diagnosis in the eyes of many mental health professionals.

The Debate About Borderline Personality Disorder

BPD is one of 10 personality disorders in the DSM-5. However, some experts have raised questions about how well this condition fits in with the other nine personality disorders. This has led to an ongoing debate about whether BPD should even be considered a personality disorder at all.

The professionals who have engaged in this debate have raised several points, including the following:

• The symptoms of borderline personality disorder overlap with many other mental health concerns, which means that many people may be misdiagnosed or miscategorized.
• BPD is highly stigmatized, which can be a source of additional distress for people who receive this diagnosis.
• The behaviors that are commonly attributed to borderline personality disorder are natural responses to particularly severe trauma.

The final point above highlights the relationship between BPD and PTSD. It has even prompted some to suggest that borderline personality disorder be renamed or replaced with a diagnosis of complex PTSD. Here’s how health and life sciences journalist Diana Kwon addressed the connection between complex PTSD and borderline personality disorder in a Jan. 1, 2022, Scientific American article:

Studies show that anywhere between 30 and 80 percent of people with BPD meet the criteria for a trauma-based disorder or report past trauma-related experiences. Most clinicians who have studied or treated people with BPD agree that not everyone diagnosed with this condition has undergone trauma—at least as it is traditionally characterized. But a growing body of evidence suggests that what constitutes “trauma” is not obvious: even when adverse experiences do not fit the textbook definition of trauma, they can leave lasting marks on the brain and heighten the risk of developing mental ailments such as BPD.

These realizations are challenging the definition and treatment of BPD.

“I think that borderline personality disorder does not fit in the concept of a personality disorder,” German psychiatrist Martin Bohus, told Kwon for her article. “It fits much better to stress-related disorders, because what we know from our clients is that there is no borderline disorder without severe, interpersonal early stress.”

The Connection Between PTSD & BPD

As Kwon’s Scientific American article noted, the connection between PTSD and borderline personality disorder seems to be related to two concerns:

• How mental health professionals define, view, and treat trauma.
• The prevalence of trauma among people who have borderline personality disorder.

These topics were also addressed in a May 2010 review in the Journal of Psychiatric Research. This review, which focused on trauma among people with both PTSD and BPD, reported the following:

• Most but not all studies have found a connection between sexual trauma and co-occurring BPD and PTSD.
• A history of sexual trauma is more common among people with both disorders than it is among those who only have BPD or PTSD.
• Some studies suggest that people who are abused at a younger age are more likely to develop co-occurring BPD and PTSD.
• People who have a dual diagnosis of PTSD and BPD are more likely to have a history of physical abuse and multiple types of abuse than are those who only have PTSD.
• These studies also suggest that an early onset of physical and verbal abuse is more common among people who have both disorders than among people who only have PTSD.

These findings are consistent with information that was presented in a Nov. 1, 2003, study of borderline personality disorder and PTSD in The American Journal of Psychiatry. That study reported elevated rates of abuse during childhood and adolescence among people who have borderline personality disorder.

“Multiple studies have reported that a history of physical and sexual abuse in childhood has a high prevalence among patients with borderline personality disorder, with some studies finding that abuse is a nearly ubiquitous experience in the early lives of these patients,” the authors of the 2003 study wrote.

PTSD, BPD, & Suicide

Understanding the close relationship between BPD and PTSD is important for those whose loved ones have both of these conditions. It is also essential for them to be aware of the increased suicide risk among individuals who have a dual diagnosis of PTSD and borderline personality disorder.

For example, the May 2010 article from the Journal of Psychiatric Research that we referenced in the previous section also noted that a dual diagnosis of PTSD and borderline personality disorder is associated with a heightened likelihood of suicide.

On their own, both PTSD and BPD have been linked to elevated rates of suicide. But the May 2010 article noted that people who have both disorders have “a significantly higher prevalence of suicide attempts.”

The link among trauma, BPD, and suicide is not a new discovery. In fact, the development of dialectical behavior therapy (DBT), which is one of the most effective forms of treatment for BPD, grew out of an effort to help traumatized people who were experiencing acute suicidal ideation.

Dr. Marsha Linehan, who created DBT, established the fundamental principles of this method while working with suicidal women in the 1970s.

“Most of the clients had experienced intense suffering. They had tragic stories. In addition, they were extremely sensitive to anything that appeared to invalidate their pain, anything that suggested that they themselves needed to change,” Dr. Linehan wrote in a Dec. 2019 article in Psychology Today. To them, standard behavior therapy, which is focused on helping people change, was a red flag.”

“I realized that what these people obviously needed was compassion—to validate them, to show that the factors driving their suffering made sense to me,” Dr. Linehan continued. “I had to see the world from their point of view. So I dumped the emphasis on change and went full-bore helping clients accept where they were in their lives.”

Treatment for Dual Diagnosis of PTSD & BPD

Dialectical behavior therapy remains a preferred form of treatment for people who have borderline personality disorder. DBT has also proved to be beneficial for people who have developed PTSD. But DBT alone may not be enough for those who have both conditions.

In 2014, the journal Current Treatment Options in Psychiatry published an article by Melanie Harned, PhD, that reviewed treatment options for PTSD and co-occurring BPD. Dr. Harnaud’s findings included the following:

• Prolonged exposure (PE) therapy and cognitive processing therapy (CPT) seem to be beneficial for people who have PTSD and mild symptoms of borderline personality disorder.
• For people who have PTSD and moderate BPD (which Dr. Harnaud defined as having active non-suicidal self-injury without life-threatening behaviors), a 12-week residential course of dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) has led to positive outcomes.
• Patients who have PTSD and severe BPD – which can include suicidal behaviors, self-harm, and multiple co-occurring concerns – may need extended treatment of a year or longer, with services such as DBT with the DBT prolonged exposure protocol (DBT + DBT PE).

Dr. Harnaud emphasized the value of providing trauma-focused care to address both PTSD and co-occurring borderline personality disorder.

“For decades, common clinical lore has suggested that providing trauma-focused treatment to individuals with BPD is likely to be ineffective at best and potentially lethal at worst,” Dr. Harnaud wrote.  “However, due to considerable advances in research over the past decade there are now a number of psychotherapies that have been shown to be both safe and efficacious for treating PTSD among BPD patients with varying levels of severity.”

Find Help for PTSD & Borderline Personality Disorder

If someone in your life has been struggling with a dual diagnosis of PTSD and borderline personality disorder, Crownview Co-Occurring Institute can help. Our dynamic programming is specifically designed for adults whose lives have been disrupted by complex mental health concerns such as BPD and PTSD. Contact us today to learn more.