How Do the Differences Between BPD and C-PTSD Affect Diagnosis?

Young adult with briefcase and short hair sits on outdoor steps outside building, hands folded under chin, looking thoughtful but distressedConsider a person in therapy whose most evident trait is their inconsistency. From session to session, they vacillate between excitement and anxiety. One week they feel fully confident, the next, totally overwhelmed. They demonstrate or recount instances of emotional instability and mood swings, alienation and avoidance, impulsiveness and overreaction, and past trauma and continuing flashbacks.

A combination of the above symptoms could lead you to two very different diagnoses: borderline personality or complex posttraumatic stress (C-PTSD). At first glance, they share a remarkably similar list of symptoms and triggers. Their potential comorbidity (the presence of both concerns) only adds to the confusion.

However, the distinction between these two conditions is real—and often critical. Research has backed up the need to categorize them separately in the Diagnostic and Statistical Manual. The best treatment practices for addressing one condition could potentially exacerbate the other condition, should a person seeking help be misdiagnosed. It is therefore vital that practitioners are aware of the differences between BPD and C-PTSD. Therapists must also be open to revisiting their initial conclusions as therapy sessions progress.

BPD vs. C-PTSD: Understanding the Differences

The key difference between BPD and C-PTSD is that symptoms of BPD stem from an inconsistent self-concept and C-PTSD symptoms are provoked by external triggers.

A person with C-PTSD may react to or avoid potential triggers with behaviors similar to those that are symptomatic of BPD. But even if their self-representation is extremely negative, it will be consistent. This differs from the inconsistent self-representation that characterizes BPD.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

As such, treatment for BPD should focus on creating a more stable, internalized sense of self. Developing a more stable sense of self can help reduce the tendency toward self-injury and dependency upon other people.

DSM guidelines also propose a longer treatment course for BPD (at least a year), as ending therapy too soon can increase the risk of relapse due to a sense of instability or abandonment. In contrast, C-PTSD treatment aims to engage traumatic memories, foster development of a positive sense of self, reduce interpersonal avoidance, and teach resetting techniques to apply when triggers are encountered.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

Even so, most diagnoses that include BPD tend to stem from complex childhood trauma of some kind. Therapists can best support the people they are working with by determining the frequency and extent of symptoms, any potential stimuli for these symptoms, and whether symptoms can be easily regulated after being triggered.

People who are experiencing C-PTSD rather than BPD typically find it easier to overcome their emotions. If past traumas are addressed and healed, the emotional reactions that result when these memories are triggered can be lessened or subdued. People with BPD, on the other hand, often find it more difficult to calm down following intrusive memories and flashbacks. The intense emotions triggered may persist, regardless of how well the memories behind them have been engaged in therapy.

Another identifier involves looking at what is missing. Consider a person who has experienced abuse. Instability, mood changes, or re-experiences may occur in discrete instances, but if a person has no history of self-harm or fear of abandonment, a diagnosis of C-PTSD is more likely. Alternatively, when these behaviors are not always accompanied by an external trigger, or occur even when expected triggers are not present, their reactions may have been caused by internal feeling stemming from BPD.

When a person begins to notice and fear their own instability, they frequently begin to exhibit other behaviors. These might include social avoidance, alienation, hypervigilance, mood changes, and increased propensity to anger. They may describe their symptoms in terminology associated with one diagnosis or the other—for example, experiencing panic attacks (BPD) as opposed to outbursts of posttraumatic stress (C-PTSD). But clinicians need to analyze the factors above in order to accurately label and consequently treat the issues underlying the shared symptoms.

Misdiagnosis Can Affect Treatment

Focusing upon the differences between BPD, C-PTSD, and comorbid BPD and PTSD allows for distinct symptom profiles to emerge, in spite of the common symptoms that may initially be more readily apparent. These separate profiles are clinically significant, since person-centered care requires accurate identification of any and all issues experienced. This ensures that treatment methods and duration can be adapted to the specific needs of each person in therapy.

It’s important for therapists to remember that the techniques that can help people with C-PTSD reset their moods may aggravate BPD symptoms. These techniques may include reminding themselves they are safe, focusing on their present surroundings, visualizing a safe location, or moving outdoors, among others. People with BPD, who often experience apparent “overreactions” or mood swings, require acknowledgment and validation of the emotions experienced, rather than a reminder that their behavior is unnecessary or irrational.

There are effective treatments for both C-PTSD and BPD. But the best approaches for each issue differ in significant ways. Consequently, misdiagnosis can be extremely detrimental. Clinicians must therefore be prepared to weigh the differences and indicators separating the two diagnoses. It’s also important to keep in mind that it may take longer than usual to confirm or revise their initial deductions.

References:

  1. Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology5, 10.3402/ejpt.v5.25097. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165723
  2. Ehrenthal, J. C., Levy, K. N., Scott, L. N., & Granger, D. A. (2018). Attachment-related regulatory processes moderate the impact of adverse childhood experiences on stress reaction in borderline personality disorder. Journal of Personality Disorders32 (Supplement), pp. 93-114. Retrieved from https://doi.org/10.1521/pedi.2018.32.supp.93
  3. Hyland, P., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … Vallières, F. (2018, April 16). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable within a treatment-seeking sample of Syrian refugees living in Lebanon? Global Mental Health, 5, e14. Retrieved from http://doi.org/10.1017/gmh.2018.2
  4. Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013, May 15). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4(1).  http://doi.org/10.3402/ejpt.v4i0.20706

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  • 12 comments
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  • Jennie P.

    September 17th, 2018 at 6:33 PM

    I spoke with my psychologist in today’s session regarding both. I must have misunderstood her because I thought she was saying i have both disorders. I just started researching today but both had a lot of symptoms that rang true. I’m so scared of being let down again when seeking help, fingers crossed.

  • Fiona B.

    January 30th, 2019 at 3:32 AM

    Good luck getting help. So much damage gets done by inappropriate diagnosis followed by either lack of treatment or the wrong treatment. I hope that you get listened too and heard, and input is helpful. From what I’ve read a small rare percent of people can have both BPD and Complex trauma co exiting. I’m. It sure how you would treat that or what the evidence base for treating it would be. Just remember it’s just a label and you are still you, the professionals are not always right , it’s easy for them to fit you into a model that justifies there existence at the end of the day. Go well, Peace.

  • St. Topper

    November 5th, 2019 at 1:45 PM

    Self harm is not always bpd.

  • Abbie

    December 5th, 2019 at 4:55 PM

    And panic attacks is not just in BPD people. I have Complex PTSD and though I look like I might have BPD, it doesn’t line up. My doctor told me some people with CPTSD have flashbacks or get “triggered” and will have extreme anxiety that transcends into panic.

  • Amy

    December 12th, 2019 at 6:15 AM

    Abbie you are so right. I am much like you

  • Anna

    January 25th, 2020 at 5:47 PM

    Can people with cptsd also crave validation for their feelings too? This scares me, because I relate so much to craving validation as I received mostly negative attention growing up and was punished for expressing my emotions (raged at as a six year old for running into a table corner, hurting my eye, and bawling over it) or opinions ( like I don’t like playing basketball, my dad’s favorite sport).

  • Jacqueline

    May 11th, 2020 at 4:08 AM

    Absolutely people with C-PTSD crave and need validation. In fact, everyone does, but people with C-PTSD even more so. And it’s very likely for anyone who has C-PTSD that they have experienced a lot of invalidation over their lives – that is part of the interpersonal trauma. Maybe look into the Emotion Coaching literature by John Gottman or the books by Dan Siegal? The Gottman emotion coaching information is often described as a method for raising emotionally intelligent children, but it’s well acknowledged that we all need to be emotion coached at times – even as adults. And we can learn to do it for ourselves. A huge part of emotion coaching is validation. One of the things that is slightly off about this article is that people who have BPD often need the same things as people with C-PTSD, it’s just that the validation needs to be careful, accompanied by helping them to mentalise, and then get more in touch with the here and now.

  • Jane

    February 4th, 2020 at 9:30 PM

     Jumping to any opposition-defiant, mood-dysregulated, labels/misdiagnoses can be so harmful and even lead to more trauma and abuse.  Not to mention, these misdiagnosis’ can follow people around forever, reshaping who they think they are or believe to be “wrong” with them. – It’s going to be amazing when C-PTSD is truly understood and our health care system gets thier mental heads out of thier butts. The DSM is going to go from 947 pages to 2.

  • Rachel

    July 10th, 2020 at 10:01 PM

    I have seen therapists and psychologists in the past, but they have been hesitant to give me a clear diagnosis. After prolonged research, I believe that I am suffering from c-ptsd. My symptoms are consistent with this diagnosis without falter. However, I have a lingering concern about BPD. I initially sought a doctor because I thought this was my problem, but it was only determined that I have ADHD and non specified anxiety disorder. She felt that many of my symptoms resulted from developmental trauma and that I would benefit more from therapy. I had signs of borderline, but it was unclear. Years following that visit I found myself in controlling relationship with a physical abusive partner. I had to spend months planning my escape because I had no support system to fall back on. I was diagnosed with PTSD, but I avoided therapy for years following out of shame and fear of being misunderstood. I thought I could push through the symptoms and move forward. I had made a lot of progress, but I also avoided intimacy and relationships. For years I would isolate, so no one would judge me for what I was going through. The last couple years, however, I have been seeking more informed help and learning about c-ptsd. Through online research, I’ve found grounding techniques and tools to identify my symptoms and triggers. It’s been incredibly healing. I’ve been in my first serious relationship in 6 years this year. Things were rocky at first, but we had finally moved to a place of support and trust, but then COVID happened. I spent the first 6 weeks locked up in bliss with my boyfriend, but then I started to feel scared and cagey. I noticed myself dissociating and then came the nightmares and panic attacks. I’m 30 years old and I have not relived those memories in years. It put an incredible strain on my relationship despite trying to explain trauma to my partner. I was the one that ultimately broke up with him, but it was mostly out of fear of abandonment. He had suggested we take a break. I’ve been over texting and wavering between wanting him completely out of my life and sheepishly hoping we can slowly build back trust and security. He wants to get back together eventually, but I have a hard time trusting him now. I truly think my abandonment fears are based on the current climate and my fear of finding work/supporting myself when I have no family to rely on. I can see where I am being needy, but it’s not typical for me in a relationship. I also genuinely fear abandonment at this point. I’m just still unclear about the difference between c-ptsd and bpd. I have a clear idea about who I am at the core, but I’ve struggled finding my true calling or a definite career path. I would say that my personality and general interests are consistent, I just feel a little lost. I’m finally looking for a therapist, but I’m trying to keep within a limited budget. I can’t afford to see a doctor right now. The abandonment thing is just concerning me. I would like to talk to a trauma counselor, but I’m afraid that I actually may have BPD. Does that effect therapy choice significantly? I still feel like c-ptsd makes the most sense for my symptoms, but please be real with me about that. Is there anyone on here that might have a few insights?

  • Lara

    February 7th, 2021 at 4:45 PM

    Rachel, you described my life to an almost exact replica.
    I suffered living with my single mother and her single mother, my gramma. They were my parents, but I didn’t realize that lorie (my mother) is actually a narcissist. I discovered this months after my gramma passed away and lorie blamed me for her death (because I got married a year before her passing and lorie is still unwed). I am turning 30 this year in December and find that I suffer from cPTSD anxiety, even though I was diagnosed with general anxiety in 2014. Everyone kept telling me I was afraid for nothing but the general anxiety diagnosis didn’t fit with how I felt. I wasn’t afraid I would be hit by cars or murdered by strangers. I was afraid my husband (then boyfriend) was going to leave me (because for context, he was my first boyfriend in high school and actually knocked me up and then fought for child support when we were both 16. Now I fear he’ll try it again).
    I tried looking for a new therapist for years, because the therapists I had during my teens would chastise me for not respecting my narcissistic mother. Yeah my own therapist told me that I was being immature and irresponsible, even though I was a teen mother. The next therapist I got in 2014, she would tell me I was being overactive to my anxiety and I wasn’t making any sense.
    I finally started seeing a counselor at the college in 2018, to try and work through my grief. But at this point I thought I had BPD because of my anger and sadness. Even though the counselor was extremely insightful and helpful, she would even question my thoughts when I brought up my past trauma. “That happened 10 years ago and you talk like it happened 10 minutes ago. Why can’t you let it go?”
    That’s when I started doing research into cPTSD and found I relate heavily to it more than my BPD self diagnosis. But again, I’ve been self diagnosing because therapists don’t want to look into my past memories or help me work through trauma. They tell me to stop bringing it up and opening old wounds. But I fight with my husband all the time. And even though he hurt me in our teens, he’s more than anything made up for his past mistake. He even blames himself and my trauma causes him depression. But we can’t get past it because of my years of trauma with lorie and her abuse.
    We’ve tried seeing a couples counselor, but we were turned away for not having enough problems. “You two don’t fight over sex or money, so you must be fine!”
    If you ever find a decent therapist, please let me know. I stopped trying after my last one in September of 2020 met me ONCE and when I started crying he immediately told me “I’m not equipped to handle you so I’m passing you along to my colleague.” And then proceeded to try and convince me I was being abandoned but the damage was already done.

  • GT Skylar

    February 9th, 2021 at 1:31 PM

    We would love to help you find someone who is a better fit than the therapists you have seen in the past. Feel free to reach out to us by email support@goodtherapy.org.

  • June

    October 15th, 2021 at 6:49 PM

    A diagnosis of C-PTSD made me feel like a switch had flipped on and there was finally a light at the end of the tunnel. 
    I’ve seen several therapists in the last few years who noted signs of PTSD, but not as an active diagnosis. Anxiety? Depression? Sure. But it didn’t feel like enough. I got so frustrated with the lack of something that could just be fixed me, that I tried to self-diagnose and entertained all of the possibilities––bipolar, brain injury? Was I exposed to black mold? Hormones out of wack? BPD felt close for the wild emotions, fear of losing everyone, but it didn’t fit. I even enrolled in two DBT programs, but it didn’t address the problem.

    I had an abusive, isolated, and homeschooled childhood.  I was raised in an orthodox cult, and temple was our only outlet to the outside world. Friends were spoonfed to me and my siblings and then ripped away at the slightest infraction. Anyone non-religious was bad. Wearing pants was bad. Chewy candy was bad. Dogs were bad. Making friends with the neighbors was bad. And I, as the curious, outgoing, and bubbly child of the group craved all of that. I was frequently punished for seeking out joy. I was constantly beaten, humiliated, and left to sleep outdoors because, well, I was bad. And I became the scapegoat among my siblings for all things bad because that is what everyone expected of me.
    My childhood taught me that opening up and sharing the honest parts of me would break me. So, I learned to lie to survive. I kept lying because being punished for a version of events you’re not emotionally connected to feels better than having your spirit broken. I grew an active imagination to cope with spending hours alone on end, locked in a room by myself as punishment. And in those hours I developed an unbreaking resolve to prove to my parents and everyone who supported them in punishing me that I could be good. Or if not good, successful. I swore I would leave that life behind. And I did. 
    But I struggled. For years, I couldn’t understand why my behaviors were so incongruent with my intentions. I didn’t expect that small things, like the smell of popcorn, the sound of chalk on a board, or certain phrases could yank me out. of the present and send me into a miniature––or in some cases, full-blown––panic attack. Emotional flashbacks. I couldn’t understand why, if I had finally found the freedom I sought my entire life, I was still trying to please the people of my old life by giving up opportunities and things I really, really wanted for fear of what they think. I was always in fight-or-flight mode because the extreme humiliation and punishment and abuse were subconsciously always a mistake away.
    I didn’t understand why I struggled with people in my new life. I couldn’t understand why I only could love the people who were hard to love or didn’t want me as much as I wanted them. Hard love was the only type I knew. I didn’t connect that my inability to let go of the ideals I was taught led me to believe that I was inherently shameful and never good enough, so I felt like I had to embellish myself to fit in. I know my lies were see-through, but I thought they were harmless.  I couldn’t understand why I kept hurting the people I loved by hiding and lying doubting their intentions. 
    I needed to lie because I couldn’t be honest about how horrible my life was. The religion. The estrangement from extended family for 12 years. My dad constantly leaving, and coming back. The run-ins with Child Protective Services. The verbal abuse. The mental abuse. My sister dying of cancer. Being punished for going outside. The physical beatings. My dad beating my mother within an inch of her life. Living in fear of my dad’s friends surveilling our home. My mother attempting suicide in front of us. Having to take care of two different grandparents who chose to be estranged as they lay dying. And then all of the failures followed me out on my own –– online connections that soured, bad friendships who used me for money, a sexual assault, financial abuse in retaliation by my dad, bad jobs, health issues I couldn’t afford to address. And perhaps the most painful of all: being cut off from my siblings. The list goes on. 
    I thought I could pack it all up, put it away, and move forward. Goodness knows I tried. I needed to address everything, but I didn’t feel like I deserved to. And when I was finally ready to, I thought that if I showed my emotional vulnerability to the people nearby, I would lose them, so I hid. And when it became unbearable, I couldn’t find the help I needed. And when the emotional flashback storm started… it just, never stopped. And the consequences of my reactions caught up to me.
    This diagnosis is a gift because I feel understood for the first time in my life. I have a great therapist who is skilled and experienced in so many of the areas I need support. For the first time in my life, I don’t feel scared. And I have hope.

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