Are BPD and complex PTSD the same disorder?

age_3_1961_2
Me at age 3 in the zone. Was the template for my BPD already laid down?

Ruji, a new commenter on this blog, made an interesting observation–that BPD should be divided into at least two subtypes: Empathy Challenged/Character Disordered (closer to NPD/ASPD) and Highly Sensitive Person with Emotional Dysregulation (closer to the type I have, although at different times in my life or when extremely stressed I have displayed the more character-disordered subtype). I agree with her. Ruji’s idea is remarkably similar to The World Health Organization’s two subtypes of BPD:

1. F60.30 Impulsive type
At least three of the following must be present, one of which must be (2):

–marked tendency to act unexpectedly and without consideration of the consequences;
–marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized;
–liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
–difficulty in maintaining any course of action that offers no immediate reward;
–unstable and capricious (impulsive, whimsical) mood.

2. F60.31 Borderline type
At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:

–disturbances in and uncertainty about self-image, aims, and internal preferences;
–liability to become involved in intense and unstable relationships, often leading to emotional crisis;
–excessive efforts to avoid abandonment;
–recurrent threats or acts of self-harm;
–chronic feelings of emptiness.
–demonstrates impulsive behavior, e.g., speeding, substance abuse

Psychologist Theodore Millon has gone even further, proposing that BPD should be divided into four subtypes:

1. Discouraged (including avoidant features): Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless.

2. Petulant (including negativistic features) Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily slighted and quickly disillusioned.

3. Impulsive (including histrionic or antisocial features) Capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, becomes agitated, and gloomy and irritable; potentially suicidal.

4. Self-destructive (including depressive or masochistic features) Inward-turning, intropunitively angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.

Millon’s Types 1 and 4 would correspond to the Highly Sensitive Person/Emotional Dysregulation type mentioned above (and therefore closer to the Avoidant/Dependent PDs); Type 2 sounds very much like NPD; and Type 3 seems closer to ASPD or Histrionic PD.

complex_ptsd
BPD symptoms are almost identical to those of Complex PTSD.

There are so many diverse–almost opposite–symptoms that can appear with this disorder that one person with BPD can be very different from the next. In fact, you can take 10 borderlines and they will all seem very different from each other, with barely any similarities in their behavior at all. One will be shy, fearful and retiring, never making waves, acting almost like an Aspie or an Avoidant; while another may break the law, lie constantly, and act obnoxious and rage whenever things don’t go their way. A borderline could be your raging boss who drinks too much and ends every annual Christmas party with one of his infamous rages, or it could be the sweet and pretty schoolteacher who goes home every night and cuts herself. She could be the come-hither seductress or the nerdy computer programmer. He may have few or no friends or a great many.

This diversity is not the case with the other personality disorders, which have more cohesiveness in the symptoms their sufferers display. So I wonder–is BPD really a personality disorder at all? Does it even exist, or is it really just a group of trauma-caused symptoms the experts in their ivory towers stuck in a single box called “BPD” because they didn’t know how else to classify them?

In fact, all these diverse subtypes have one thing in common–they are all very similar or identical to the symptoms of someone with complex PTSD (C-PTSD). People with C-PTSD are often misdiagnosed as Borderlines because their behaviors can be just as baffling and manipulative, and both disorders also include dissociative, almost psychotic episodes. Extrapolating from that, I wonder if ALL borderlines actually have C-PTSD.

Earlier today I posted an article outlining 20 signs of unresolved trauma, and I was struck by how similar these were to the symptoms of BPD. And there is also this article that Ruji just brought to my attention that also describes how remarkably similar the two disorders are, but that the idea of fear of abandonment (which is recognized as the root cause of BPD) is not recognized as a factor in causing PTSD and that may be part of why they have been kept separate.

The BPD label, like any Cluster B label, is very damaging to its victims because of the “evil and character-disordered” stigma it carries. One psychologist has even included us, along with narcissists, among the “People of the Lie”!

Yes, it’s true some borderlines do act a lot like people with NPD or even Malignant Narcissism or ASPD, but most probably do not, and are really much more similar to people with Avoidant or even Dependent personality disorders, which hurt the sufferer more than anyone else. But if you have a BPD label, people start backing away from you slowly due to the stigma. Therapists are reluctant to treat you because they assume you will be either difficult and hateful in therapy sessions, or will never get better. Insurance companies won’t pay claims where there is a BPD diagnosis, because it’s assumed there is no hope for you. I’ve had this problem when I’ve tried to get therapy. I remember one therapist who I had seen for the intake session, who told me he needed to obtain my psychiatric records before we could proceed. The session had gone smoothly and I felt comfortable with him. A few days later I received a phone call and was told he did not treat “borderline patients” and wished me luck. So that’s the kind of thing we’re up against if we’ve had the BPD label slapped on us.

Also, as an ACON blogger who works with a lot of victims of narcissistic abuse, my BPD label sometimes makes people wary of me and they begin to doubt that my motives here are honest. At first I was reluctant to talk about my “Cluster B disorder” here, because I knew it might be a problem for some ACONs, who think borderlines are no better than narcissists. But I eventually decided that to hide it away like an embarrassing family secret would be misleading so I “came out” about having BPD (I never actually lied about it, but played it down in the beginning and rarely mentioned it). I’m glad I fessed up, but there have been a few people who left this blog after I came out about it or began to doubt my motives. So there’s that stigma and it’s very damaging.

Both C-PTSD and Borderline PD are caused by trauma. Both are complex defensive reactions against future abuse and both involve things like splitting, dissociation, psychotic episodes, self-destructiveness, wild mood swings, and behavior that appears to be narcissistic and manipulative.

The way I see it, the only real difference between C-PTSD and BPD is that the traumatic event or abuse happened at an earlier age for someone with BPD, perhaps during toddlerhood or infancy, while all forms of PTSD can happen at a later age, even adulthood. But the symptoms and defense mechanisms used to avoid further trauma are the same for both.

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Clearing up some misunderstandings about BPD.

borderline

There seems to be a lot of misunderstanding about borderline personality disorder. I’ve noticed many people seem to confuse it with narcissistic personality disorder (NPD). While there ARE some overlapping symptoms (and it’s even been speculated by a number of mental health professionals that BPD is actually a less severe form of NPD), they are quite different from each other. I’d like to clear up a few of these misunderstandings and discuss both the similarities and the differences.

New DSM Criteria for BPD.

According the the DSM-V (2013), these are the diagnostic criteria for BPD (the new list of criteria is quite long and ponderous so I will not attempt to talk about each of these points here):

A. Significant impairments in personality functioning manifest by:

1. Impairments in self functioning (a or b):

a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.

b. Self-direction: Instability in goals, aspirations, values, or career plans.

AND

2. Impairments in interpersonal functioning (a or b):

a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.

b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

B. Pathological personality traits in the following domains:

1. Negative Affectivity, characterized by:

a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.

d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.

2. Disinhibition, characterized by:

a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.

3. Antagonism, characterized by:

a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

Is it really true that Borderlines can’t feel empathy?

welcome_to_me_photo
BPD patient “Alice” (Kristen Wiig) in “Welcome to Me.”

The very first thing that stood out to me (and was not included in the older DSM criteria) is “lack of empathy.” Yes, it is a fact that many borderlines have difficulty feeling empathy under normal circumstances, but the reasons for this are vastly different than the lack of empathy seen in people with NPD.

Most people with BPD have the capacity to feel empathy, and can feel very guilty when they become aware (or it’s pointed out to them) that they have treated others badly, but because Borderlines have great difficulty regulating their emotional reactions and have an unfortunate tendency to lose themselves in their own drama when they perceive they are being attacked, at those times they can “forget” that others exist, and this can lead to them acting selfishly and disregarding the feelings of others. This can appear very narcissistic. It’s not that they CAN’T feel empathy though, because they certainly can. They can also feel remorseful. But it may take a disaster (such as losing a good friend or a broken relationship) for them to realize the damage their impulsive and selfish behavior has caused. If their bad behavior is pointed out to them by someone else–such as when the character Alice in the movie “Welcome to Me” loses her best friend Gina, who tells her how much she was hurt by Alice’s insults against her–they will feel remorse and try to make amends in whatever way they can.

Borderlines just want to be accepted.

wizard-of-oz2

Unlike narcissists, borderlines hate to be hated. Narcissists like any form of attention–negative or positive (and some even prefer to be hated!) while borderlines only want to be loved and thought of in a positive manner. Most of them WANT to be good people and WANT to be liked, but don’t always act in ways that make them seem very nice, due to their impulsivity and tendency to act out whatever emotions they are feeling at the moment.

Impulsivity is a primary issue with a borderline–a trait not shared by narcissists (but IS shared with people with ASPD)–because they fail to think ahead and consider consequences of their bad behavior.

Borderlines can act narcissistic because of their deep seated need to feel accepted. Most hate themselves (as do narcissists) and some can act grandiose and full of themselves in their attempts to be liked and admired. Deep inside, they feel worthless. It’s not hard to take down their braggadocio, however. Cut a borderline down to size and they may react with rage or tears (as will a narcissist) but are also more likely than a narcissist to admit you are right and they are really just worthless losers. They might even apologize profusely for acting so out of line.

I can’t help but think of the Wizard in The Wizard of Oz. An insecure little man who stood behind a curtain projecting the face of a raging tyrant onto a huge screen. When Toto pulled back the curtain to reveal who the “Wizard” really was, and Dorothy upbraided him for being a “very bad man,” the Wizard immediately became humble and apologized profusely to the group, telling them that yes, he was just a humbug. Some people have said the Wizard was a narcissist, but I think his behavior was more typical of a borderline. A narcissist would have continued to insist on his superiority, even with his true nature having been revealed–and his true nature would not have been so benign. The Wizard’s intentions for Dorothy and her friends were also good.

While a narcissist may rage and perhaps even use tears (to manipulate others into feeling sorry for them), they will almost never admit their wrongdoing or admit they are anything other than God’s gift to the world. Doing so is far too dangerous to them.

Why Borderlines act selfishly.

BPD_cartoon

A borderline who is not under stress or in the midst of an emotional drama, or has learned to control their impulses through behavioral training like DBT–dialectical behavior training which was developed by Marsha Linehan (it does work–I can attest to its efficacy), can certainly feel empathy for others, and can be genuinely good and kind people. Genuine kindness and concern for others is rare in a narcissist and almost unheard of in a malignant narcissist. Borderlines generally have this capacity, but unfortunately, if they haven’t learned to control or regulate their emotions, their ability to feel for others or show a conscience is eclipsed by their own drama, which at the moment becomes all-important. They really just don’t know what they are doing, but if you call them out or make them suffer consequences, in most cases they will try to make it up to you.

Borderlines don’t live a lie.

cluster_b

Borderlines do not wear masks, as narcissists do. They cannot pretend to be someone they are not (or if try to, they usually fail miserably, like the wizard in The Wizard of Oz). They are not trying to fool you, even though to avoid rejection, they can be manipulative and use some of the same games (gaslighting, blame-shifting, rages, etc) that narcissists do. Borderlines, if anything, show TOO MUCH of themselves–and that includes the bad along with the good. With a borderline, it’s all WYSIWYG. They can’t wear a mask, because they lack the ability to plan things out ahead of time the way someone with NPD does. Wearing masks requires cunning and the ability to lie. While borderlines can and do lie (usually to exaggerate the pain they are facing or to idealize/devalue someone else), they can’t lie about who they are or what they’re feeling. In that sense, they’re even more honest than the average non-disordered person.

Idealization/devaluation in borderlines and narcissists.
hashtag_borderline

Both narcissists and borderlines do tend to idealize and devalue other people, and both are guilty of black-or-white thinking. But the motives for this behavior are different. A narcissist idealizes someone they see as a good source of narcissistic supply. They do not see the source of supply as a person, but will put them on a pedestal as long as they’re providing enough supply. Should the victim stop providing supply (or the narcissist just becomes bored and needs a new source of supply), the narcissist devalues and discards the victim, without mercy or regret.

Most borderlines idealize and devalue others based on their need for acceptance and love, not the need for supply. If they perceive another person as good and kind, and accepting of them, they will tend to idealize the person and sometimes become clingy and needy (a narcissist can be clingy and needy too, but for different reasons). If the borderline feels the other person losing interest or pulling away from them, they may suddenly, without warning, devalue the other person and reject them. They do this not to be mean, but to avoid being rejected themselves. This explains the “I hate you…don’t leave me” or “come closer…go away” behaviors many borderlines show. It’s confusing and contradictory to others, but it helps them to avoid the inevitable rejection they believe is coming to them. Borderlines live in constant fear of being rejected; narcissists live in constant fear being ignored–losing their “drug” of narcissistic supply. While their behaviors may seem similar on the surface, the motives behind them are quite different.

A borderline is not usually deliberately malicious or sadistic. It’s not their intention to hurt others or cause them misery, even though they unintentionally do it all the time because they have so much trouble controlling their impulses. They usually are not even aware how much their unpredictable and contradictory behavior is confusing or hurting others. If a borderline is made aware of what they are doing, they are far more likely to seek therapy than a narcissist, because someone with BPD wants more than anything to be loved and accepted. A narcissist just doesn’t care what you think of them, as long as you are paying attention to them. Of course, there are some low-mid spectrum narcissists who have enough self awareness and hate the fact they can’t feel the more sublime emotions (love, empathy, joy) of a normal person, and those few may actually seek help too.

BPD is maladaptive to the victim.

linehan_biosocial
Marsha Linehan’s diagram that shows why BPD doesn’t work well for the sufferer. (click to enlarge)

Borderline personality disorder is ego-dystonic: that is, it isn’t adaptive to the sufferer and their behaviors cause them as much or more misery than it causes others. People with any ego-dystonic disorder or mental illness–depression, anxiety, phobias, certain personality disorders such as Avoidant, Borderline or Dependent–are more likely to seek treatment because they aren’t happy with the way they behave and feel. They don’t necessarily blame others for their own misery, the way a narcissist will do.

Borderlines are also far more likely than narcissists to engage in suicidal ideation or even attempt suicide when they become depressed. They are self-destructive and more dangerous to themslves than others. A narcissist is not as likely to consider or attempt suicide, but if they do, they are more likely to attempt to “take you with them.”

Narcissistic personality disorder is ego-syntonic: that is, it usually is adaptive to the sufferer and in most cases their bad behaviors don’t bother them at all (they don’t care how you feel), they only bother others. This is why narcissists are so unlikely to seek treatment, unless they have lost their sources of supply and are undergoing severe depression (narcissistic crisis). Narcissists are miserable people, but they are far more likely than borderlines to blame others for their own misery.

Both disorders are included under the Cluster B category of personality disorders because both involve a malfunction of emotional regulation. In a narcissist, emotion is strong but is hidden and masked; in a borderline, emotion is strong but cannot be hidden or regulated at all. Both disorders cause others misery, but a narcissist lives a lie; a borderline generally does not.

BPD as a defense mechanism that arises in early childhood.

scared_child

Both NPD and BPD (and all Cluster B disorders) arise out of childhood from early attachment disorders with caregivers. Both are desperate attempts not to be hurt anymore and have their origins in abuse or neglect as young children. Most narcissists and borderlines were abuse victims as children. Both narcissists and borderlines are incredibly sensitive–so much so, they have constructed almost intractible defense mechanisms to avoid further pain and hurt. Unfortunately for the borderline, their defense mechanism of overreaction to everything is maladaptive and hurts them more than they can hurt anyone else. But due to this, they are far more likely to seek treatment.

Upcoming Post:
Later on, I plan to post an article about Marsha Linehan’s DBT and other therapies for people suffering from Borderline Personality Disorder. (They are similar to the methods used for people with NPD).

I hate my BPD.

bpd_crazy

Sometimes my BPD rears its ugly head. It comes off as narcissism to people who don’t understand. I don’t always understand it either, and because impulsivity is a factor, when I act out in Borderline ways, I’m not even always aware at the time I’m doing it. Sometimes it doesn’t become clear to me until it’s pointed out to me later, and then I’m all, “Oh my God, what have I done?”
Then I beat myself up with guilt and shame, which is what I did today.

Even though I learned tools for handling my BPD when I was hospitalized (for Bipolar II) in 1996 and have found those tools helpful, sometimes it’s not enough and my BPD gets the best of me. I’ve been accused of being narcissistic before. I know I’m not a narcissist, but I can understand why some people might think so.

bpd_things

God, I really hate this disorder. Out of all my disorders, it’s the worst one. It trips me up so often and destroys friendships and makes people think they can’t trust me. Then it’s very hard to convince them I never had ill intentions, but acted impulsively out of whatever emotion at the moment was driving my behavior.

I think blogging was the first step in my recovery from narcissistic abuse, but I’ve reached a place where a lot of emotional garbage that was buried and frozen because of my PTSD is coming up to the surface and it HURTS A LOT. I just wanted to cry all day. I didn’t but I wanted to.

I will still blog of course (I don’t plan to ever stop either), but my BPD is showing more and I think all the weird emotions I’m feeling that I can’t understand are becoming too much for me to handle alone anymore. It was suggested to me that I really need to seek counseling at this point. I know there are free or low cost mental health services in my area I could look into.

I hate my BPD. I wish it would just go away and stay away forever. It’s caused me and people I cared about so much misery. It’s destroyed so many friendships. I don’t want this anymore. I can live with my Aspergers and even enjoy it, but being a Borderline really sucks. 😦
Just one more way my FOO fucked me over…

“Coming out” about my BPD

Hand of a child opening a cupboard door

On November 22, 2014, I wrote an article about my daughter Molly (not her real name), who I suspected of having NPD due to having been used as a flying monkey by her father for many years. I prayed it was “just” BPD.

Last month she was evaluated and her Axis II diagnosis was Borderline Personality Disorder (BPD). While BPD is a Cluster B disorder and shares a number of traits with narcissism, it’s more amenable to treatment because a Borderline does have a conscience and the ability to feel empathy–but their tendency to fly off the handle, their insecurity/neediness, and propensity to engage in self destructive activities that sometimes hurt others masks the fact they really aren’t bad people. My daughter actually has a huge heart and cries when she sees someone suffering or in pain, so it fits that NPD wasn’t her diagnosis. Still, I’m relieved she’s been officially cleared of it.

I was diagnosed with BPD myself in 1996. I have been hesitant to call attention to it on this blog or talk about it much, because of its close association with NPD and other “character disorders” like ASPD. At the time I was diagnosed I was in an inpatient psychiatric setting, where I was also diagnosed with Bipolar I (major depression with fewer or no manic episodes), generalized anxiety, PTSD, Avoidant PD (I didn’t know you could have two PD’s at once back then), and substance/alcohol abuse. At the time I was not diagnosed with Aspergers (that was much later, and I was self diagnosed at first).

I definitely had all the traits of a borderline, but in the hospital and in outpatient therapy following my stay, I learned ways to control my BPD traits, such as my tendency to fly off the handle easily, act impulsively without thinking how it would harm others, idealize/devalue people (black or white thinking), abuse drugs and alcohol, and generally coming off as being very self centered and oblivious to the needs of others.

DSM_borderline
Click to enlarge.

For a time back in the early 1980s I even test drove narcissism, but as an essentially empathic person who suffers from a lot of guilt and shame, and has no desire to hurt others, narcissism didn’t work for me, and I am so grateful for that (even though I became a codependent doormat instead).

In therapy, I remember a method we were taught called “turtling”–which basically means to imagine yourself as a turtle when you feel yourself about to act/react in Borderline, impulsive, or self destructive ways. Turtling calls for enough insight to recognize your feelings prior to acting on them. You imagine going inside your shell to think about things before you act. I remember in the hospital we made “turtle” totems to keep as reminders to always think before we acted and ask ourselves why we felt the way we did. I still have the little clay turtle I made. I remember also being given a workbook for people with BPD with many helpful exercises and activities to help us recognize and control our behavior. It did help me a lot.

clay_turtle

Today I don’t think I display many BPD traits, but I don’t think I’m cured either. When I’m very depressed, frightened or angry, those BPD traits pop back up like unwanted pimples. I still remember the lessons from my therapy and still look at my little turtle or a picture of a turtle to remind myself to go inside myself and not react until I think things through and process my feelings.

Because this is a blog for survivors of narcissistic abuse and many (if not most) survivors think of narcissists as demons or monsters, I was hesitant to talk about my BPD much, because it’s a Cluster B disorder and is so close to NPD in many ways. The disorders are easily confused with each other. A person with full blown BPD can seem very much like one with NPD, but for the Borderline, the motive behind their unpredictable and sometimes destructive behavior is fear of abandonment and insecurity. For the narc, it’s for obtaining supply. Some people seem to think of people with BPD as almost as bad as narcissists. Some of them are.

So that’s why I’ve been reluctant to talk about this. But again, from Day One I committed to honesty and I hope I won’t be judged too harshly for “coming out” as a person with BPD.

borderline
Borderline personality disorder.

My daughter, I’m happy to say, knows almost as much about narcissism as I do now, and has been reading my blog. She came across the above article where I speculated she might have NPD and she was so worried about that it made her cry. We had a long discussion about that. Since then, she has been improving a lot and says my blog has helped HER! She says she’s proud of me for having the courage to start this blog. And I have to say, I’m just as proud of her. Here’s my article describing how healing and emotional that talk we had was. I think we will both be just fine.

My next article, which I will write later today, will be about how malignant narcissists can transform a good person into an evil one. They can infect you with their illness. That’s another reason why they’re so dangerous.