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Borderline Personality Disorder & other Trauma Responses

When we experience intense, stressful, and traumatic life events, we often expect ourselves and others to not respond in an intense, stressful, or traumatic manner.  Trauma is a complicated phenomenon that can’t be defined in a neat little box, and this is part of what makes coping with trauma responses so difficult; we don’t have a box that can contain our responses. Typically, trauma responses are our minds and bodies responding normally to abnormal experiences.

The manual used for making psychiatric diagnoses in the US, the Diagnostic and Statistical Manual for Mental Disorders (DSM), defines trauma as “exposure to actual or threatened death, serious injury, or sexual violence.”  However, many psychotherapists take issue in this definition, calling it reductionistic and exclusionary.  The symptoms associated with trauma-related disorders, like intrusive thoughts and memories, difficulties with emotions and feelings of self-worth, or alterations in reactivity, appear in those who have experienced a variety of stressful events – not just exposure to death, injury, and sexual violence.  Yet, the DSM only acknowledges these reactions as symptomatic of a trauma-related disorder if a person has experienced one of the few events mentioned.  Psychologist Dr. Nicole LePara defines trauma more inclusively, describing this phenomenon as “any experience that overwhelms our capacity to cope and process emotions effectively.”  Per the DSM, we can be emotionally abused and neglected, grow up witnessing family members experience serious mental illness, or be displaced from our family of origin, and these experiences would not be deemed “traumatic” – even if we experience all of the symptoms of a trauma-related disorder.  While the DSM attempts to define trauma in a neat little box, the experiences they exclude merely spill over into neighboring diagnostic categories, leaving clients inadequately diagnosed and treated.

Trauma, though not defined in this way by the DSM, is a subjective experience. When we experience an event, or events, that overwhelm our ability to cope, our bodies and minds respond in predictable ways – these are called “trauma responses.”  For some folks, these trauma responses manifest as what we call “Posttraumatic Stress Disorder” or “PTSD.”  In order to meet criteria for this diagnosis, several symptoms need to be present.  If all required symptoms are not present, but a person is experiencing significant distress related to a traumatic experience and some of the symptoms of PTSD, they may be diagnosed with an Adjustment Disorder, Other Specified Trauma and/or Stressor Related Disorder, or an Unspecified Trauma and/or Stressor Related Disorder.  These disorders are a cluster of “trauma related disorders.”  Sometimes, though, people experience other clusters of symptoms that do not match “trauma related disorders.”  That is not to say that their disorder is unrelated to their trauma, though. 

One metric for identifying childhood trauma is the “Adverse Childhood Experiences” checklist, also known as “ACES.”  ACES are childhood experiences likely to adversely impact a person; the more of these experiences a person has, the more likely they are to have adverse impacts. 

There is robust research suggesting that with each exposure to an adverse childhood experience, the likelihood of developing a mental health disorder increases.  Greater ACES exposure has been associated with greater likelihood of mood disorders (i.e., depressive disorders, bipolar disorder), anxiety disorders (i.e., generalized anxiety disorder, panic disorder, agoraphobia), psychotic disorders (i.e., schizophrenia, schizoaffective disorder), obsessive-compulsive disorders (i.e., OCD, body dysmorphic disorder), eating disorders (i.e., anorexia nervosa, binge eating disorder), personality disorders (i.e., borderline personality disorder, narcissistic personality disorder), sleep disorders, alcohol and other substance use disorders, and suicidal ideation and attempts.  In fact, childhood trauma is associated with 45% of childhood-onset disorders and 32% of adult-onset disorders.

It is not just childhood trauma that increases our likelihood of developing a mental health disorder, however.  Exposure to trauma, at any age, is predictive of major depressive disorder and generalized anxiety disorder.  While exposure to trauma does not always lead to a mental health disorder, trauma is a shock to our system, and it is expected that such a shock will cause – at the very least – some stress.

While our manual for diagnostics in the US, the DSM, does not acknowledge most ACES as factors that can lead to trauma-related disorders (even though people with exposure to ACES most definitely DO develop trauma-related disorders quite often), other diagnostic manuals do acknowledge these experiences.  In the International Classification of Diseases (ICD), the diagnostic manual used by the World Health Organization, trauma is defined broadly as, “exposure to an extremely threatening or horrific event or series of events.”  

The ICD also includes a diagnosis not included in the DSM, that has led to some controversy among mental health professionals.  This diagnosis is Complex Posttraumatic Stress Disorder, or C-PTSD.  C-PTSD is a trauma-related disorder where all criteria for PTSD are met, in addition to “severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and 3) difficulties in sustaining relationships and in feeling close to others.”  The controversy caused by this C-PTSD is not that it isn’t valid, but rather that it has significant overlap with other mental health disorders, most notably with Borderline Personality Disorder.  Some even argue that Borderline Personality Disorder is the same as C-PTSD, or that Borderline Personality Disorder is a subtype of C-PTSD.  

Borderline Personality Disorder is a disorder characterized by persistent difficulties with mood regulation, frequent mood swings, impulsive behavior, and trouble forming stable interpersonal relationships.  Approximately 90% of those diagnosed with Borderline Personality Disorder report experiencing abuse or neglect as children, and the presence of childhood trauma has been associated with the development of this disorder.  Most major models of this disorder’s development note that childhood adversity likely shapes the emergence of this personality type. However, Borderline Personality Disorder is frequently misdiagnosed.  Women in particular are often incorrectly diagnosed with this disorder, in part due to stereotypes about women being “emotional” or “hysterical.”  Conversely, men with Borderline Personality Disorder are under-diagnosed.  There is also significant overlap between this disorder and C-PTSD, as well as other conditions.  Further, someone who is highly dysregulated during a stressful situation may present with mood swings, impulsivity, and interpersonal difficulties, leading to a misdiagnosis.  For example, when I worked on an inpatient psychiatric unit for people with severe eating disorders, I saw many patients incorrectly labeled as “borderline” because they displayed emotional outbursts and inappropriate social behavior while hospitalized – an extremely stressful time for them.  Many of these patients were responding in this manner due to the severity of their eating disorder, and were acting out of character – these temporary behaviors, thus, were not likely indicative of a personality disorder.

Accurate diagnosis is often crucial for adequate treatment.  While treatment tailored for someone with Borderline Personality Disorder may also help a person with C-PTSD due to the overlap in symptoms, an accurately tailored approach will be even more helpful.  There are nuanced differences between these diagnoses that can be difficult to tease apart, so I’ve created a venn diagram depicting some of what distinguishes these two.  At their core, C-PTSD, Borderline Personality Disorder, and all other disorders in which trauma has influenced their development, are trauma responses.  If you are experiencing any iteration of a trauma response, there is nothing wrong with you; you are simply reacting normally to abnormal situations.

Have questions or think you might be struggling with trauma responses? Help is available!  While I cannot currently provide individual psychotherapy services privately, you can click here to learn more about working with me in other capacities.  Check out my social media below for free resources and updated information on my services!  

If you are having serious thoughts of killing yourself or hurting someone else, call 911 or go to the nearest Emergency Room.  You may also receive help at:

  • 988 Suicide & Crisis Lifeline: call or text 988 or chat
  • Crisis Textline: Text “Start” to 741741
  • Trevor Lifeline (LGBTQIA+ support): call 866-488-7386

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