700284

research-article2017
APY0010.1177/1039856217700284Australasian PsychiatryKulkarni

Australasian
Invited Article Psychiatry
Australasian Psychiatry

Complex PTSD – a better 1­–3

© The Royal Australian and
New Zealand College of Psychiatrists 2017

description for borderline Reprints and permissions:

sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1039856217700284
https://doi.org/10.1177/1039856217700284

personality disorder? journals.sagepub.com/home/apy

Jayashri Kulkarni  Professor of Psychiatry and Director MAPrc, Monash Alfred Psychiatry Research Centre (MAPrc), Melbourne,
VIC, Australia

Abstract
Objective: To consider the use of the diagnostic category ‘complex post-traumatic stress disorder’ (c-PTSD) as
detailed in the forthcoming ICD-11 classification system as a less stigmatising, more clinically useful term, instead
of the current DSM-5 defined condition of ‘borderline personality disorder’ (BPD).
Conclusions: Trauma, in its broadest definition, plays a key role in the development of both c-PTSD and BPD. Given
this current lack of differentiation between these conditions, and the high stigma faced by people with BPD, it seems
reasonable to consider using the diagnostic term ‘complex post-traumatic stress disorder’ to decrease stigma and
provide a trauma-informed approach for BPD patients.

Keywords:  complex post-traumatic stress disorder, borderline personality disorder, trauma, stigma, neurobiology

B
orderline personality disorder (BPD) is one of the effective treatment, but there are relatively few trained
most stigmatised conditions in psychiatry today. therapists, and financial access issues. The pharmaco-
BPD has a high prevalence, significant comorbidi- therapy is not clear and there is no recognised ‘anti-BPD’
ties and considerable mortality. International estimates medication. The diagnostic label itself provokes contro-
report BPD prevalence of between 1% and 4%,1–4 and versy; the condition has been described in various ways
a recent large community study found a high lifetime over many years. Psychoanalyst, Adolph Stern, coined
prevalence of 5.9%.5 BPD has been found to affect the term ‘the border line group’ in 1938. The term ‘bor-
males and females equally, although women and derline personality’ was used to indicate the condition
younger adults experience higher levels of disability.5 fell between psychotic and neurotic disorders. However,
The National Health and Medical Research Council the word ‘borderline’ is often misinterpreted as ‘not
of Australia recently estimated that 23% of outpatient quite an illness but on the border’. The term ‘personality
and 43% of inpatient mental health service users have disorder’ can minimise this mental illness to mean ‘bad
a diagnosis of BPD.4 To complicate this further, BPD is behaviour’, often invalidating the sufferer who ironi-
a great ‘mimicker’ of a number of other psychiatric ill- cally already feels invalid.
nesses, including psychosis, mood disorders and anxiety
Summing all of these factors, plus the challenging nature
disorders, alongside a high level of comorbidity, which
of the symptoms expressed and experienced by sufferers
may decrease the number of BPD-affected individuals
of BPD – such as rage, anger, self-mutilation and perhaps
reported who require health service resources.
therapeutic nihilism felt by many healthcare practition-
The direct public health impact and cost of BPD is mark- ers when working with patients with BPD, leads to the
edly significant. People with BPD have high use of emer- heavy stigma attached to this mental illness.
gency departments, crisis and primary care services. The
economic burden of BPD outweighs other psychiatric
disorders, but resources allocated to this patient popula-
tion are remarkably low.
Corresponding author:
The neurobiological aetiology of BPD is still in its Jayashri Kulkarni, Monash Alfred Psychiatry Research Centre
infancy, with many unanswered questions about the (MAPrc), Level 4, 607 St Kilda Road, Melbourne, VIC 3004,
diagnostic issues and overlap with other conditions. Australia.
Dialectical behavioural therapy is an acknowledged Email: jayashri.kulkarni@monash.edu

1
 Australasian Psychiatry 

Emphasising the role of trauma in for Mortality and Morbidity Stats) released by the World
BPD Health Organization (WHO) on 31 May 2016. The
boundaries between c-PTSD and BPD remain vague.26
The aetiology of BPD is multifactorial, but mounting evi- Currently, the main difference is the assumption that
dence supports the role of early life trauma as an impor- symptoms of c-PTSD are sequelae of exposure to trau-
tant factor that drives significant neurobiological matic stress, which is not inherent in the current DSM-5
changes and the subsequent development of BPD.6–8 definition of BPD.
Adults diagnosed with BPD likely have a history of psy- BPD and PTSD are relatively distinct with regard to the
chological trauma.9–13 The concept of childhood trauma precise qualitative definitions of their diagnostic fea-
includes emotional deprivation or inconsistency, pro- tures, but nevertheless have substantial potential over-
longed parental absence and harsh, critical parenting.14 lap in their symptom criteria.
In a large sample, Zanarini and colleagues found that
85% of BPD sufferers had experienced childhood The DSM-5 revised PTSD criteria include new symptoms
trauma,12 with associated insecure attachment com- reflecting pervasive negative changes in affect, identity
monly associated with such trauma. and behaviour which overlap with four other BPD crite-
ria (i.e. identity disturbance, potentially self-damaging
As a result, traumatic victimisation and compromised impulsivity, self-harm, affective instability); therefore
primary caregiving relationships have been hypothesised there is potential overlap with seven of nine BPD criteria.
to be key aetiological factors in the subsequent develop-
ment of BPD.7,15,16 BPD sufferers are at risk of further The WHO International Classification of Diseases, 11th ver-
abuse in adulthood,9,10,17 and cumulative abuse across sion (ICD-11), scheduled for launch in 2017, will contain
their lifespan.9,10,13,17 Although severe childhood sexual two related diagnoses, PTSD and c-PTSD, within the spec-
abuse (i.e. prolonged, violent, multiple perpetrators, trum of trauma and stress-related disorders.1,27 There will
physical penetration) was found to be the most consist- be a section classifying ‘personality disorders’ including
ent type of childhood trauma associated with BPD symp- BPD. The key symptoms of emotional dysregulation and
toms and impairment,13 neglect is also a risk factor.18 dissociation leading to behavioural correlates of deliber-
ate self-harm, rage and poor empathy are common to
It is now well-established that childhood maltreatment both conditions. Hence, phenomenology, particularly a
coupled with genetic vulnerability evokes a stress cross-sectional history of symptoms experienced, will
response that can promote pathophysiological pro- not be of much value in separating c-PTSD from BPD.
cesses.19 This results in disruptions in neuroendocrine,
neurochemical and neuroimmunological systems with
feedback system loops between all of the critical central Neurobiology of PTSD, c-PTSD and
nervous system anatomical and neurochemical path- BPD
ways.20 Childhood maltreatment can trigger major neu-
robiological destabilisation, with major disruption of In brief, stressors as a general rule activate the HPA axis.
hypothalamic–pituitary–adrenal (HPA) axis functioning Changes in HPA function likely result from differences in
and cortisol production.21 Although direct mechanisms the severity and timing of psychological trauma, the pat-
are yet to be defined, studies have highlighted epige- terns of signs/symptoms, comorbid conditions, personal-
netic modifications to be the environmental/gene link. ity, gender and genetic makeup.28 Subsequent alterations
in noradrenaline, dopamine, serotonin and GABA sys-
tems are significant, fluctuant and have been described
PTSD, complex PTSD and BPD in traumatised individuals,29 with no real differentiation
between the three conditions. To date, the neurochemis-
Twenty years ago, complex post-traumatic stress disor-
try and neurostructural changes seen in c-PTSD, BPD and
der (c-PTSD) was defined as a syndrome with symptoms
PTSD do not clearly differentiate the three conditions.
of emotional dysregulation, dissociation somatisation
and poor self-esteem, with distorted cognition about
relationships, following traumatic interpersonal abuse.
Current summary of classifications
c-PTSD was proposed as an alternative for understanding
and treating people who had suffered prolonged and From the literature on the forthcoming ICD-11, the dia-
severe interpersonal trauma, many of whom were diag- gram shown in Figure 1 may demonstrate the current
nosed with BPD.22,23 placement of these three conditions.
The arguments about whether c-PTSD is a valid and use-
ful clinical syndrome,24,25 or not, continue. Although
Clinical observations and ways
the diagnosis ‘complex PTSD’ is not included in the
forward
DSM-5, the current ICD-10 includes a diagnosis of
enduring personality change after catastrophic experi- The role of trauma in the early or current lives of our
ence (EPCACE) in the disorders of adult personality and patients with BPD is often understated in the develop-
behaviour section; this is regarded as equivalent to ment of management plans.30 The patient’s need to repress
c-PTSD, according to ICD-11 Beta Draft (Joint Linearization painful memories, coupled with clinicians’ reluctance to

2
Kulkarni

years of prospective follow-up: description and prediction of recovery. Am J Psychiatry

2013; 170: 111–120.

8. Zanarini MC, Laudate CS, Frankenburg FR, et al. Reasons for self-mutilation reported by bor-
derline patients over 16 years of prospective follow-up. J Pers Disord 2013; 27: 783–794.

9. Zanarini MC, Frankenburg FR, Reich DB, et al. Adult experiences of abuse reported by
borderline patients and Axis II comparison subjects over six years of prospective follow-
up. J Nerv Mental Dis 2005; 193: 412–416.

10. Zanarini MC, Frankenburg FR, Reich BD, et al. Violence in the lives of adult borderline
patients. J Nerv Mental Dis 1999; 187: 65–71.

11. Zanarini MC, Gunderson JG, Marino MF, et  al. Childhood experiences of borderline
patients. Compr Psychiatry 1989; 30: 18–25.

12. Zanarini MC, Williams AA, Lewis RE, et al. Reported pathological childhood experiences
associated with the development of borderline personality disorder. Am J Psychiatry
1997; 154: 1101–1106.
Figure 1.  The placement of PTSD, c-PTSD and BPD
13. Zanarini MC, Yong L, Frankenburg FR, et al. Severity of reported childhood sexual abuse
according to ICD-11.
and its relationship to severity of borderline psychopathology and psychosocial impair-
ment among borderline inpatients. J Nerv Mental Dis 2002; 190: 381–387.

probe into early trauma downplays the role of trauma in 14. Fonagy P, Target M and Gergely G. Attachment and borderline personality disorder. A
its broadest definition, in BPD. There are many complex theory and some evidence. Psychiatr Clin North Am 2000; 23: 103–122.
aetiological factors in BPD, but the role of trauma is impor- 15. Vermetten E and Spiegel D. Trauma and dissociation: implications for borderline person-
tant to consider in implementing effective treatment. ality disorder. Curr Psychiatry Rep 2014; 16: 434.

The ICD classification diagnosis of ‘complex PTSD’ 16. Bradley R, Jenei J and Westen D. Etiology of borderline personality disorder: disentangling
the contributions of intercorrelated antecedents. J Nerv Mental Dis 2005; 193: 24–31
appears to be a major subset of the current BPD diagno-
sis. The term ‘complex PTSD’ may be less stigmatising 17. McGowan A, King H, Frankenburg FR, et al. The course of adult experiences of abuse in
patients with borderline personality disorder and Axis II comparison subjects: a 10-year
and opens the possibility of developing and applying
follow-up study. J Pers Disord 2012; 26: 192–202
more trauma-informed treatment strategies.
18. Putnam KM and Silk KR. Emotion dysregulation and the development of borderline per-
sonality disorder. Dev Psychopathol 2005; 17: 899–925.
Disclosure
The author reports no conflict of interest. The author alone is responsible for the content and 19. Lupien SJ, McEwen BS, Gunnar MR, et al. Effects of stress throughout the lifespan on
writing of the paper. the brain, behaviour and cognition. Nat Rev Neurosci 2009; 10: 434–445.

20. Grosjean B and Tsai GE. NMDA neurotransmission as a critical mediator of borderline
Funding personality disorder. J Psychiatry Neurosci 2007; 32: 103–115.
The author received no financial support for the research, authorship, and/or publication of 21. Lee RJ, Hempel J, TenHarmsel A, et al. The neuroendocrinology of childhood trauma in
this article. personality disorder. Psychoneuroendocrinology 2012; 37: 78–86.

22. Herman JL. Complex PTSD: a syndrome in survivors of prolonged and repeated trauma.
References J Traumatic Stress 1992; 5: 377–391.
1. Lenzenweger MF, Lane MC, Loranger AW, et  al. DSM-IV personality disorders in the 23. Spinazzola J, Blaustein M and van der Kolk BA. Posttraumatic stress disorder treatment
national comorbidity survey replication. Biol Psychiatry 2007; 62: 553–564. outcome research: The study of unrepresentative samples? J Traumatic Stress 2005; 18:
2. Jackson HJ and Burgess PM. Personality disorders in the community: a report from the 425–436.
Australian national survey of mental health and wellbeing. Social Psychiatry Psychiatr 24. Herman J. CPTSD is a distinct entity: comment on Resick et al. J Traumatic Stress 2012;
Epidemiol 2000; 35: 531–538. 25: 256–257.
3. Trull TJ, Jahng S, Tomko RL, et al. Revised NESARC personality disorder diagnoses: gen- 25. Resick PA, Bovin MJ, Calloway AL, et  al. A critical evaluation of the complex PTSD
der, prevalence, and comorbidity with substance dependence disorders. J Pers Disord literature: implications for DSM-5. J Traumatic Stress 2012; 25: 241–251.
2010; 24: 412–426.
26. Ford JD and Courtois CA. Complex PTSD, affect dysregulation, and borderline personal-
4. National Health and Medical Research Council. Clinical practice guideline for the man- ity disorder. Borderline Pers Disord Emotion Dysregul 2014; 1: 9.
agement of borderline personality disorder (2012). Australia: National Health and Medi-
cal Research Council, 2013. 27. Cloitre M, Garvert DW, Brewin CR, et al. Evidence for proposed ICD-11 PTSD and com-
plex PTSD: a latent profile analysis. Eur J Psychotraumatol 2012; 4: 1594-1601.
5. Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity
of DSM-IV borderline personality disorder: results from the Wave 2 national epidemio- 28. Meewisse M, Reitsma JB, De Vries G, et al. Cortisol and post-traumatic stress disorder
logic survey on alcohol and related conditions. J Clini Psychiatry 2008; 69: 533–545. in adults. Systematic review and meta-analysis. Br J Psychiatry 2007; 191: 387–392.

6. Lewis KL and Grenyer BF. Borderline personality or complex posttraumatic stress disor- 29. Sherin JE and Nemeroff CB. Post-traumatic stress disorder: the neurobiological impact
der? An update on the controversy. Harvard Revi Psychiatry 2009; 17: 322–328. of psychological trauma. Dialogues Clin Neurosci 2011; 13: 263–278.

7. Zanarini MC, Frankenburg FR and Fitzmaurice G. Defense mechanisms reported by 30. Xiao CL, Gavrilidis E, Lee S, et al. Do mental health clinicians elicit a history of previous
patients with borderline personality disorder and Axis II comparison subjects over 16 trauma in female psychiatric inpatients? J Mental Health 2016; 25: 359–365.