Having both BPD and PTSD

Borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) are commonly caused by trauma. PTSD and BPD also share various symptoms, including emotional dysregulation and fear of abandonment. However, though the two conditions can occur together, they are different disorders.

What is BPD?

BPD is characterized by an inability to regulate emotions. The result is intense mood swings, impulsive behavior, and strained or unstable relationships with others.^[1]

Furthermore, people with BPD typically have low opinions of themselves. This unstable self-concept, along with the mood swings and impulsivity previously mentioned, add even more strain to interpersonal relationships. 

Complicating matters is that people with BPD usually have an intense fear of abandonment. As a result, they might quickly advance relationships to prevent their significant other from leaving them. Conversely, BPD patients might quickly end a relationship before the other person can. Whilst people with BPD may try to quickly advance relationships by idealizing the other person, they are also likely to ‘split’ on the person, which is where they devalue them due to any perceived hurt, rejection, or if they anticipate abandonment.

Other common symptoms of BPD include:^[1] 

• Difficulty controlling anger or inappropriate anger responses
• Dangerous behaviors (e.g., substance abuse, unsafe sex, reckless driving)
• Feelings of emptiness
• Self-harm (e.g., cutting)
• Suicidal ideation 

Patients with BPD might also have feelings of dissociation. For example, they might feel detached from themselves, as though they’re watching themselves from outside their own body.

The symptoms discussed above differ for every person with BPD, both in type and severity. What’s more, the duration of symptoms varies widely from one person to the next.

Causes of BPD

As noted earlier, one of the primary causes of BPD is trauma. Childhood trauma like physical abuse or neglect tends to be more prominent in people with BPD than people with other personality disorders.^[2] However, other risk factors might lead to the development of this disorder, including:^[1]

• Biopsychosocial factors – This includes childhood abuse, abandonment by loved ones, and other difficulties during childhood.
• Family history – People with a parent or sibling with BPD are more likely to develop BPD as well.
• Brain functioning – Studies indicate that people with BPD may have impaired brain development within the pre-frontal cortex, which is responsible for emotional regulation and impulse control.This area of the brain is usually fully formed by the age of 25, however for people with BPD this development may have been disturbed due to the long-term effects of trauma.

Though these things put people at higher risk for the development of BPD, they are not a guarantee that BPD will occur. The development of this disorder is instead the result of a myriad of factors.^[1]

What is PTSD?

PTSD often occurs after someone experiences a traumatic event e.g., a natural disaster, mass shooting or a physical or sexual assault. Whilst most people recover from traumatic experiences like these, others develop prolonged feelings of fear, dread, and stress reactions that last one month or longer. 

During that period, someone with PTSD might experience such severe symptoms that they cannot maintain daily activities. For example, fear might prevent someone with PTSD from going to work. As another example, a patient with PTSD might shut out loved ones because of persistent feelings of guilt and trouble feeling happiness and other positive emotions.

PTSD symptoms occur in four specific areas:^[3] 

• Avoidance (e.g., attempting not to think about or discuss the traumatic event)
• Re-experiencing (e.g., flashbacks or recurring memories of the event)
• Cognition and mood (e.g., self-blame or feelings of isolation)
• Arousal and reactivity (e.g., heightened startle response or difficulty falling asleep)

To be diagnosed with PTSD, one must experience one avoidance and one re-experiencing symptom, as well as two symptoms each in the cognition and mood and arousal and reactivity symptoms realms.^[3]

Causes of PTSD

In addition to trauma, PTSD might develop due to several risk factors. These include:^[3]

• History of mental illness – This includes personal mental illness or a family history of mental illness.
• History of substance abuse – Again, either on a personal level or a family history.
• Lack of social support after the traumatic event. Likewise, added stress after the trauma (e.g., losing one’s job after surviving a terrorist attack) might make PTSD more likely to develop.

Complex Post-Traumatic Stress Disorder

There is another type of PTSD of which to be aware – complex PTSD, or cPTSD. This disorder is similar to PTSD but with additional symptoms that include:^[4]

• Emotional dysregulation
• Difficulty feeling connected to others
• Difficulty maintaining relationships (both romantic and platonic)
• Feelings of guilt, shame, or worthlessness

These symptoms are not just highly similar to PTSD but also to BPD. In fact, cPTSD was initially suggested as an alternative diagnosis to BPD.^[5] Whilst they can be difficult to distinguish, research shows that cPTSD is distinct from BPD.^[5][6] However, cPTSD is not a separate disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) or the newer text revision (DSM-5-TR).^[7]

Can you have both BPD and PTSD?

Studies show that PTSD and BPD commonly occur together, which is known as ‘co-morbidity’. In the United States, for example, 25-30 percent of patients with one disorder meet the criteria for the other. Furthermore, 30-70 percent of patients with BPD report having PTSD at some point in their lives.^[5] 

Another study using data from the United States shows that 29 percent of patients who had PTSD in the last year also meet the criteria for BPD. Conversely, 32 percent of people with BPD also meet the diagnostic criteria for PTSD.^[8]

Complex PTSD and BPD also commonly occur together. A Danish study ^[9] found that 79 percent of patients with BPD also had cPTSD. Likewise, patients with a cPTSD diagnosis had BPD 40.5 percent of the time. For many patients, it isn’t a complex PTSD vs BPD issue but a combination of the two.

How does treatment for BPD and PTSD differ?

When considering PTSD vs BPD symptoms, there are a lot of commonalities. However, there is less in common regarding the treatment of these psychiatric disorders. BPD treatments focus primarily on psychotherapy, while PTSD treatments include therapy and medications.

BPD Treatments

Psychotherapy is far and away the most common treatment for BPD. Psychotherapy is a form of talk therapy with a mental health professional. This type of therapy typically takes place in a one-on-one setting, though in the case of DBT, group settings are also common.

Two types of psychotherapy are common for treating BPD:^[1]

• Cognitive Behavioral Therapy (CBT)– CBT is effective in helping BPD patients identify inaccurate beliefs about themselves. Likewise, it helps patients change their behaviors and improve their ability to interact with others. For instance, CBT can help reduce the severity of mood swings, which can also help improve interpersonal relationships.
• Dialectical Behavior Therapy (DBT)– DBT is a treatment specifically designed for people with BPD. The primary goal of DBT is to increase a patient’s ability to be present and mindful while teaching practical skills for managing emotions, improving interpersonal relationships, and minimizing self-destructive behaviors.

Another treatment option is art therapy. This type of therapy helps people express emotions and feelings in nonverbal forms. Likewise, mentalization-based therapy (MBT), a form of psychotherapy, can help people with BPD examine and assess their thought processes and determine if they’re helpful, healthy, or based on reality.^[10]

Medication is not typically a treatment for BPD. Instead, a mental health professional might prescribe medications for specific symptoms (e.g., antidepressants and mood stabilizers for mood swings).

However, medication can treat PTSD. This is a primary difference in treating these disorders.

Specifically, PTSD is often treated with selective serotonin reuptake inhibitors (SSRIs) like fluoxetine or serotonin and noradrenaline reuptake inhibitors (SNRIs) such as venlafaxine. These drugs may help manage specific PTSD symptoms related to mood, appetite, and sleep. Additionally, other medications may be prescribed to address symptoms. These include sleep aids to help a patient fall asleep and stay asleep ^[3] or antipsychotics for symptoms such as hyperarousal and paranoia.

PTSD treatment also often involves psychotherapy, which is often used alongside medication, in order to achieve the best results. The types of psychotherapy used to treat PTSD often differ from those used for BPD:^[3]

These include:

• Cognitive Restructuring – Cognitive restructuring helps people with PTSD adjust their thoughts about a traumatic event. Usually, people with PTSD assign blame to themselves and feel extreme guilt, even if the trauma wasn’t their fault. This type of therapy can help change that view to think about the event in a more realistic manner.
• Exposure Therapy – Exposure therapy involves gradually exposing a person with PTSD to the source of their fear. This is done in a very safe way with the support of a therapist and typically results in reduced symptoms and less distress when thinking about the traumatic event.

In some instances, Cognitive Processing Therapy (CPT) is the selected modality for treatment.^[11] CPT is a type of cognitive-behavioral therapy that focuses on identifying, challenging, and modifying unrealistic beliefs about the source of trauma. 

Eye movement desensitization and reprocessing (EMDR) is a treatment for PTSD that has been widely researched and shown to be effective. This type of therapy is highly structured and involves the patient focusing on traumatic memories while undergoing bilateral stimulation. This treatment can reduce the intensity of emotions related to traumatic memories.^[11]

How to manage comorbid BPD and PTSD

If you have BPD and PTSD, the first thing to do is contact a mental health professional. PTSD and BPD symptoms can worsen without proper treatment, making the situation even more severe than it already is.

As outlined above, many different treatments are available for BPD and PTSD, but a qualified mental health provider is needed to implement these strategies. If you have BPD and PTSD, ask a friend or family member to go with you to meet with a mental health provider. Having the support of a loved one is beneficial for your progress through treatment.

Other management strategies include:

Focus on what you’re feeling 

Use that mindfulness to work through your emotions. For example, if you feel sad and lonely, try listening to music that makes you feel happy. If you’re angry or frustrated, do something healthy to help release those feelings, like exercising.

Avoid alcohol, nicotine, and other drugs 

Whilst it may seem like alcohol and drugs ease the symptoms initially, they will worsen symptoms long term. People with BPD and PTSD are more likely to experience drug and alcohol issues, so get help from a specialist if you feel your drinking or drug using is becoming a problem. 

Look after your physical health

Eat right, get plenty of rest, and take time to exercise, and you’ll likely find that your symptoms improve. 

If you find yourself having suicidal thoughts or engaging in self-harm, seek help immediately by letting a close friend or relative know, and call your mental health professional or 911.