Borderline personality and PTSD

[Alemo]

Maybe I’m way off base here, but I seem to recall hearing that borderline and PTSD are closely related, with some speculating that the two disorders are on a spectrum with each other.

In my (very limited) clinical experience I have seen a few patients mostly veterans who have a significant trauma history and who are chronically hallucinating (complex visual hallucinations, related to trauma) and display irritability, a lability that inhibits their relationships and communication, and sometimes a perseveration on their trauma to the degree that it could be construed as an identity disturbance (or at least an overvaluing of this component).

Certainly changes in connections between limbic (amygdala) structures and the frontal lobes are implicated in both.

I’m curious to hear your all’s popular opinion on the similarities and differences in this disorder (yes I know I could do a literature search but sometimes conceptualizations stimulate thinking)

Also I need to read that Body keeps the score book....

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[whopper]

Most patients I've seen with Borderline PD are women who've been sexually traumatized as a child or young adult or in some other way highly devalued.

 

[deleted736562]

Not really sure about the two being on a spectrum. I think they have quite a distinct flavor. A key distinction is that patients with PTSD usually shun human interactions and their symptoms are tightly connected to a specific trauma they experienced. The core of BPD is deeply interpersonal which is not (at least always) the case with PTSD. Having said that, I guess you can argue that if the trauma happened early enough in one's life, it can lead to character disturbances that ultimately evolve into BPD.

 

[NickNaylor]

I agree with @fpsychdoc and think of these disorders similarly. The core feature of borderline PD is interpersonal (and intrapersonal) dysfunction, and typically this is the most prominent feature, though the patient may not come at you with this as the presenting complaint. This can occur with PTSD, obviously, but to a much lesser degree and typically secondary to the symptoms of PTSD themselves (e.g., irritability, a "change in personality" following the trauma, etc.). I think of PTSD as essentially chronic adrenergic overload, and these are typically the presenting symptoms: hypervigilance, hyperarousal, symptoms of anxiety, etc.

 

[psychapp121]

I agree with @fpsychdoc and think of these disorders similarly. The core feature of borderline PD is interpersonal (and intrapersonal) dysfunction, and typically this is the most prominent feature, though the patient may not come at you with this as the presenting complaint. This can occur with PTSD, obviously, but to a much lesser degree and typically secondary to the symptoms of PTSD themselves (e.g., irritability, a "change in personality" following the trauma, etc.). I think of PTSD as essentially chronic adrenergic overload, and these are typically the presenting symptoms: hypervigilance, hyperarousal, symptoms of anxiety, etc.

chronic adrenergic overload sounds like GAD, are those related

 

[clausewitz2]

chronic adrenergic overload sounds like GAD, are those related

There's a reason PTSD lived in the anxiety disorders section of the DSM for a long time.

 

[splik]

There's a reason PTSD lived in the anxiety disorders section of the DSM for a long time.

indeed the only disorder that did not belong in the anxiety disorders section was GAD!

 

[psychapp121]

indeed the only disorder that did not belong in the anxiety disorders section was GAD!

how could generalized anxiety not be an anxiety disorder

 

[cara susanna]

PTSD can have more "complex" symptoms (basically, emotional and interpersonal dysregulation) that look like BPD. It's really hard to differentially diagnose. These symptoms are not predicted by trauma type, number of exposures, or age of exposure. IMO, a diagnosis of BPD should never be 100% conclusive if there is untreated PTSD, unless those symptoms were present prior to the index trauma.

The Body Keeps the Score is good, but just a head's up that van der Kolk's been pushing some pretty unscientific things lately about trauma treatment.

 

[splik]

how could generalized anxiety not be an anxiety disorder

GAD as defined by DSM-IV and 5 (t had different diagnostic criteria in DSM-III) is not an anxiety disorder. It does not cluster with specific phobia, social anxiety disorder, PTSD, or OCD which have significant overlap and respond to exposure based treatment. Factor analyses show GAD clusters with MDD more than anxiety disorders. in ICD-10 and prior iterations of the DSM, GAD was a fear based diagnoses, which all the other anxiety disorders are (though OCD and PTSD have now been removed into their own categories), but GAD as currently conceptualized is a worry based diagnosis. Rumination is also a key feature of depression. So much so, in many cultures depression and anxiety aren't really distinguished at all. Worldwide, mixed anxiety depressive disorder is the most common psychiatric presentation, though the diagnosis is curiously absent from DSM-5 (it is included in ICD-10).

 

[Alemo]

GAD as defined by DSM-IV and 5 (t had different diagnostic criteria in DSM-III) is not an anxiety disorder. It does not cluster with specific phobia, social anxiety disorder, PTSD, or OCD which have significant overlap and respond to exposure based treatment. Factor analyses show GAD clusters with MDD more than anxiety disorders. in ICD-10 and prior iterations of the DSM, GAD was a fear based diagnoses, which all the other anxiety disorders are (though OCD and PTSD have now been removed into their own categories), but GAD as currently conceptualized is a worry based diagnosis. Rumination is also a key feature of depression. So much so, in many cultures depression and anxiety aren't really distinguished at all. Worldwide, mixed anxiety depressive disorder is the most common psychiatric presentation, though the diagnosis is curiously absent from DSM-5 (it is included in ICD-10).

That’s interesting. It does seem as if GAD is commonly diagnosed with major depression, but it’s frequently not at all clear to me if the anxiety follows an episodic pattern and is related to depression, or is chronic and separate from depression (though it’s not for lack of history taking). Sometimes I just describe anxiety as a symptom of major depression rather than making a separate diagnosis.

In a patient who one suspects may have a borderline/PTSD comorbidit, would you recommend DBT before trauma based therapy ( it would seem that DBY skills may be necessary to do trauma therapy)?

It’s also hard (this comes up not uncommonly) when there are childhood traumas that might not meet strict PTSD criteria as a traumatic event, but then such an event occurs later in life (meanwhile the reactivity, irritability, hallucinations, and anxiety symptoms have persisted since adolescence).

 

[cara susanna]

In a patient who one suspects may have a borderline/PTSD comorbidit, would you recommend DBT before trauma based therapy ( it would seem that DBY skills may be necessary to do trauma therapy)?

It’s also hard (this comes up not uncommonly) when there are childhood traumas that might not meet strict PTSD criteria as a traumatic event, but then such an event occurs later in life (meanwhile the reactivity, irritability, hallucinations, and anxiety symptoms have persisted since adolescence).

No, research suggests that building skills prior to trauma treatment is not necessary. The few studies that have been done examining DBT skills prior to formal trauma work did not show any benefit to retention rates or treatment outcomes. Trauma treatment itself builds emotion regulation skills. The only contraindication is if the patient is not stable (in DBT-PE this defined as engaging in suicidal or self harm behavior in the past 60 days) or displaying therapy-interfering behaviors that would make engagement in trauma therapy impossible.

Here's an article criticizing the "step based" trauma treatment approach.

 

[whopper]

I don't think Borderline and PTSD are on the same spectrum. Highly comorbid, e.g. Agoraphobia and Panic Disorder, but are two separate phenomenon. Anyone, however, traumatized as a child has a much higher chance of borderline.

How do I know? You see several with just one and not the other.

 

[cara susanna]

I don't think Borderline and PTSD are on the same spectrum. Highly comorbid, e.g. Agoraphobia and Panic Disorder, but are two separate phenomenon. Anyone, however, traumatized as a child has a much higher chance of borderline.

How do I know? You see several with just one and not the other.

I agree that they aren't on the same spectrum as you can have BPD without any trauma history.

 

[PsyDr]

1) Due to the intermingling of treatment and disability in VA settings, one must accept the significant potential for malingering in veteran settings.

2) Johson's 2006 longitudinal study of parenting behaviors and personality disorders is a key resource.

 

[birchswing]

GAD as defined by DSM-IV and 5 (t had different diagnostic criteria in DSM-III) is not an anxiety disorder. It does not cluster with specific phobia, social anxiety disorder, PTSD, or OCD which have significant overlap and respond to exposure based treatment. Factor analyses show GAD clusters with MDD more than anxiety disorders. in ICD-10 and prior iterations of the DSM, GAD was a fear based diagnoses, which all the other anxiety disorders are (though OCD and PTSD have now been removed into their own categories), but GAD as currently conceptualized is a worry based diagnosis. Rumination is also a key feature of depression. So much so, in many cultures depression and anxiety aren't really distinguished at all. Worldwide, mixed anxiety depressive disorder is the most common psychiatric presentation, though the diagnosis is curiously absent from DSM-5 (it is included in ICD-10).

In the benzodiazepine ads from the early 1980s, the indicated diagnosis was "anxiety associated with depression." It's common across both ads for Ativan and Xanax, so I assume it was an official diagnostic term.

Is that what morphed into GAD?