NHS England has brought out some guidance around psychological therapy for PTSD which includes Complex PTSD. Why is this interesting? Well, for a long time many have felt that Complex PTSD is a much more helpful way of understanding people who are given the diagnosis of Borderline Personality Disorder. BPD is the mental health diagnosis most associated with childhood trauma with up to 80% of those who receive the diagnosis having lived through neglect, abandonment and/or abuse.
What I want to do here is have a look through the new guidelines and see what they might mean for those currently understood as having a disordered personality rather than a response to traumatic life events.
The document begins by listing the 5 features of Post Traumatic Stress Disorder.
For a diagnosis of PTSD you need to have ALL 5
For a diagnosis of Complex PTSD you need ALL the following 3 features in addition:
The guide goes into all these features in more detail. I’ll focus on the ones for CPTSD but first I’m going to list the diagnostic criteria for BPD. The 9 criteria are below and remember, to win a diagnosis you need to hit any 5 out of the 9.
Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.
Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.
We’re going to keep these criteria in mind as we look through the guidance.
“Heightened emotional reactivity” could look a lot like “affective instability”.
“Self destructive behaviour” could look a lot like “suicidal behaviour, gestures or threats, or self-mutilating behaviour”.
“Violent outbursts” might look a lot like “Inappropriate, intense anger or difficulty controlling anger.”
Those who are seen as “reckless or self destructive” could also be viewed as displaying “Impulsivity in at least 2 areas that are potentially self-damaging".
We also have “Dissociative symptoms when under stress” which could look a lot like “stress-related paranoid ideation or severe dissociative symptoms”.
Finally for this section, “emotional numbing” might look decidedly like “Chronic feelings of emptiness”. Now I’m not a doctor, but I’d say that 6 things associated with ‘BPD’ that could easily be seen as being described in the CPTSD criteria.
Its worth bearing in mind that severe problems with affect regulation sounds like emotions or moods changing a lot. This is important for the next section
Next we have:
The BPD criteria that relates to this most might be “chronic feelings of emptiness.” Above we had “severe problems with affect regulation” which implies a roller coaster of emotion. I’ve spent about 15 years working with people who get a BPD diagnosis and while an unstable sense of self image might be the criteria, I generally see people who consistently feel worthless, hopeless and deserving of punishment. Grandiosity and over confidence is not a problem we generally have to work on. That isn’t to say the people I work with don’t laugh, joke and have fun, but it takes a small reminder of the past to take them to a place where they again feel vulnerable, afraid and awful. The CPTSD description is a lot more applicable to those I work with who are given the BPD diagnosis than the actual BPD criteria. Its probably worth wondering whether the affect/presentation can change, while the underlying beliefs remain constant. When those beliefs are constant, it might look a lot like chronic feelings of emptiness.
Lastly….
So the closest the BPD criteria come to this is “A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation”. Now if this ‘splitting’ of people into good and bad is really a thing, it would certainly result in “difficulties sustaining relationships”. While the person “may (and the “may” is doing a lot of heavy lifting here) “avoid deride and have little interest in relationships” it would also make sense that those who felt worthless and carried huge feelings of guilt and shame might hold on tight to anyone who showed a glimmer of care or affection. “Persistent difficulties in sustaining relationships” could be a result of “frantic efforts to avoid real or imagined abandonment. The CPTSD description is not emphatic about relationships being avoided, only that they are difficult.
Just for emphasis, I hope I’ve showed that more kindly descriptions of the BPD criteria can be found in the CPTSD descriptor. The only one I couldn’t crow bar in was “Identity disturbance: markedly and persistently unstable self-image or sense of self.” Now if I was someone carrying a BPD diagnosis who wanted to change it to CPTSD, I’d be really interested in these descriptions that NHS England has put out. If “A Identity disturbance with markedly or persistently unstable self-image or sense of self” could be applied to my presentation well, that’s just 1 criteria. If I met every criteria for CPTSD and 1 for BPD I’d be arguing 1 criteria does not a diagnosis make.
This might help with a conversation about changing diagnosis. You don’t have to, but if you want to this might get you off to a good start.