How PTSD can look like Borderline Personality Disorder
The first couple of therapy sessions with Trina were rollercoaster rides. One second she was excited about a new job and all of the possibilities it presented, and the next she was anxious and overwhelmed from being a caretaker to her mother. When she came back for her second session she was nervous and depressed over the thought that her long-time partner might leave her, and by the third, the issue seemed to have disappeared from her mind completely. Despite her therapist’s several attempts to help her regulate the extremes of her emotional responses, she continued to experience intense reactions and couldn’t seem to pinpoint where they originated from.
The initial thought of the therapist was that she had Borderline Personality Disorder (BPD). But after further assessment, Trina was missing some necessary ingredients. She did not have an intense fear of abandonment – she had successfully and happily lived ten years without a partner – and she had no history of suicidality or self-harming behaviors. While she did, perhaps, occasionally overindulge with alcoholic beverages, this behavior was not and had never been at an addictive level. All of these characteristics are necessary for someone to be diagnosed with BPD, so what could she possibly be suffering from instead that caused such severe emotional reactions?
It wasn’t until Trina’s therapist discovered her history of severe childhood abuse, an abusive previous partner, and the fairly recent death of her father, that this question was answered. Trina called her outbursts panic attacks, but when one of these episodes was activated in front of the therapist, it was clear that this was not panic but rather a post-traumatic stress disorder (PTSD) experience. Now knowing the source of the symptom, her therapist was able to help her work through her trauma and calm her moods naturally, stabilizing her behavior very quickly.
Mistaking a PTSD reaction for BPD behavior is a common error. Here are some similarities and differences between the two:
- Traumatic history: The recent revision in the DSM-5 of PTSD allows for diagnosis in repeated abuse cases and not just a one-time occurrence. Child abuse is a perfect example of this. A child who was locked in a closet as punishment might have a PTSD response in an elevator as an adult. Left unhealed, the abusive behavior still impacts the adult in real-time. Likewise, a person with BPD can feel past trauma as if it was still present because they are so acutely aware of their feelings.
- Difference: When the trauma is healed for a person with PTSD, the emotional reaction is minimal and subdued. However, the person with BPD is unable to divorce themselves of their emotions, even the more negative ones long after the trauma has occurred and been healed. Their emotional memory brings the past into the present as if it was happening right now.
- Mood swings: To an untrained eye, a PTSD response could look like a panic attack, an overreaction, or unnecessary dramatization. When a person with BPD feels threatened or fears abandonment, their response could look the exact same way. These momentary intense highs and lows are frequently identified as mood swings when they might be something else.
- Difference: A person experiencing a PTSD reaction can reset quickly by becoming aware of their current surroundings, going outdoors, or listening to a calming voice reminding them that they are safe. None of these methods work for a person with BPD, in fact, that only aggravates the situation. Instead, acknowledgment of their pain combined with empathy and agreement for how they feel helps a person with BPD.
- Alienation of others: Neither a person with PTSD nor a person with BPD wants to alienate themselves from others, but unfortunately this happens. Instead of taking the time to understand a situation and work through the crisis, other people avoid or run away. This aggravates anxiety in persons with PTSD or BPD and can make their experience worse.
- Difference: Outside of the triggering PTSD moments, persons with this condition don’t normally overreact. However, when they have many triggers, this can seem more frequent than not. Once the triggers are identified and processed, the reactions are more restrained. A person with BPD is triggered more intensely by internal feelings or fears than they are external situations or experiences like those with PTSD. By learning to manage the strength of their emotions, persons with BPD can get better.
Had Trina been treated for BPD instead of PTSD, her condition might have gotten worse instead of getting better. An accurate understanding and assessment of the two are necessary to avoid making this error. While being able to differentiate BPD and PTSD may be difficult at first, try using some of these qualifiers as tips to help you navigate the patient’s situation and assist them in a way that they will benefit from most.
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Posted under: abuse Borderline Trauma Writings from Christine
Can you speak to the responses from antisocial pd and trauma. I have a client who meets criteria for aspd. He also has abused amphetamines and cocaine for over 10 years and now suffers paranoia.
At times intense reactions usually when alone he becomes fearful of someone coming to attack him and arms himself, barricades himself. He describes the physical symptoms of a panic response. It becomes a challenge to decide on which approach to use in treatment for these episodes. Is the paranoia part of his aspd mindset (yes) and this interferes with creating safety work I would do for trauma. Is this often a part of drug intoxication (yes). The theme of being invaded is consistent with past events of being the victim of home invasions/kidnapping/stabbing, however he has also been the perpetrator of such events.
It sounds like he might need in-patient treatment.