Key moments, in order
Define terms before debating. Baseline PTSD in the DSM-5 more or less covers what the ICD-11 calls complex PTSD.
Both labels get caricatured. BPD is not the person's fault and they deserve understanding; people with complex PTSD can be manipulative and are responsible for what they do.
Survivors of childhood abuse often accumulate many different diagnoses before the underlying complex post-traumatic syndrome is recognized.
Think of complex PTSD as a big bucket that contains a bunch of small buckets, and one of those small buckets is BPD.
A skeptical view: complex trauma should not exist as a concept. It is clinically useful and can describe many patients accurately, but it is flawed in its origin.
Do not care what you call it; give the right treatment. Whatever the patient prefers to call it, call it that.
Often we are all describing the same clinical problems in different language, because of poor practice in who clinicians give diagnoses to and how they give them. The problem at the outset was not categorization but a lack of alliance-building and collaborative care between equal parties.
The criteria build on each other: a trauma (A), it comes back as re-experiencing (B), the person avoids it (C), and so on.
Criterion D is a large, persistent change in how the person feels and relates to themselves and others. It is almost characterological, but it happens in people with no prior personality problems, and in clear cases outside war veterans you see it almost without exception.
The injury is not a fear response circumscribed to the trauma. It is a wholesale inhibition or change of the person's personality due to developmental issues.
In the ICD, complex PTSD is PTSD plus disturbances of self-organization, which include difficulties regulating emotions.
Do not call it complex PTSD just because someone has a bunch of little-t traumas in their history.
A mnemonic: PTSD is FEAR (fright, exposure, avoidance, re-experiencing). Complex PTSD is BAD FEAR, adding betrayal, affect regulation and developmental impact.
Complex PTSD is described as a history of subjection to totalitarian control, which is already a very loaded way of writing its criteria.
It is a useful term: a lot of patients do not have typical BPD symptoms but do show the complex PTSD picture.
Clinicians reserve the diagnosis for patients they dislike and give CPTSD, or nothing, to patients they like. Borderline has become code for "I don't like this person" or the most annoying patient in the hospital.
You can have severe personality dysfunction that does not fit neatly into BPD or NPD, and a lot of providers get caught up on that.
Looking at criterion A and level of personality functioning, we have hardly made a borderline personality disorder diagnosis in two years. Most of the time we point to maladaptive personality traits or problems of personality functioning instead.
Explain it plainly: your personality is the way you are used to dealing with yourself and other people, and how you think and feel about both. It comes from what you went through growing up and who you are.
The APA now says there is good evidence for transference-focused psychotherapy, mentalization-based therapy and good psychiatric management. More important than the specific model is that the patient is in a talk therapy they commit to.
The McLean Screening Instrument for BPD is a quick tool, especially when a patient asks whether they have CPTSD.
Externalizing behaviors, such as impulsivity, efforts to avoid abandonment and temper outbursts, lean BPD. In BPD relationships get super close and then explode; in CPTSD there is more avoidance.
BPD is not binary, which gives you a way to talk about traits when full criteria are not met. A spectrum view lets you say this is not a mood disorder without saying their personality is broken.
Some patients use the label as a defense against looking at their personality dysfunction. The McLean screen and a conversation about traits let you open that conversation earlier.
The simple approach: is there PTSD or not? If there is, most of the problems get subsumed under PTSD.
These conversations go well nearly every time, whether you say BPD or traits. Patients feel understood and less alone, and it is a relief to have an identifiable condition instead of a treatment-resistant depression no one can figure out.
Be very careful that any diagnosis, especially a culturally laden or emotionally invested one, does not function as resistance to appropriate treatment, consciously or not.
A diagnosis conversation goes well less because of the words you use than because of what you feel inside: if you truly care and want to help, it shows.
Manipulation and being a bad person are not part of the diagnosis whatsoever.
Worry less about the single label and more about whether you and the patient share an understanding of them and agree on the treatment plan.
Treatments overlap heavily. The main difference is that complex PTSD may call for more trauma-focused therapy, such as EMDR, and BPD for more work on interpersonal functioning and emotion regulation.
Clinicians need a deeper understanding of personality and the borderline conditions, not just the stereotype versions.
There is no use giving a diagnosis the patient cannot explain in their own words from what has happened in their life. Ask what they understand it to mean: you may agree on the label and mean very different things by it.
A commonly recommended book is Complex PTSD: From Surviving to Thriving by Pete Walker, written by someone with complex PTSD.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.