Borderline Personality Disorder (BPD) and Complex Posttraumatic Stress Disorder (CPTSD): A Network Analysis in a Highly Traumatized Clinical Sample

A network perspective on posttraumatic stress disorder and comorbid borderline personality disorder symptoms

Background: Comorbidity between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) is surrounded by diagnostic controversy and although various effective treatments exist, dropout and nonresponse are high.Objective: By estimating the network structure of comorbid PTSD and BPD symptoms, the current study illustrates how the network perspective offers tools to tackle these challenges.Method: The sample comprised of 154 patients with a PTSD diagnosis and BPD symptoms, assessed by clinician-administered interviews. A regularised partial correlation network was estimated using the GLASSO algorithm in R. Central symptoms and bridge symptoms were identified. The reliability and accuracy of network parameters were determined through bootstrapping analyses.Results: PTSD and BPD symptoms largely clustered into separate communities. Intrusive memories, physiological cue reactivity and loss of interest were the most central symptoms, whereas amnesia and suicidal behaviour were least central.Conclusions: Present findings suggest that PTSD and BPD are two distinct, albeit weakly connected disorders. Treatment of the most central symptoms could lead to an overall deactivation of the network, while isolated symptoms would need more specific attention during therapy. Further experimental, longitudinal research is needed to confirm these hypotheses.Trial registration: ClinicalTrials.gov identifier: NCT03833453.

A Systematic Review of the Assessment of ICD-11 Complex Post-Traumatic Stress Disorder (CPTSD) in Young People and Adults

Complex post-traumatic stress disorder (CPTSD) was introduced in the International Classification of Diseases (ICD) 11 in 2013 to simplify diagnosis and increase clinical utility. Given the recent ICD-11 conceptualisation, there is no standard approach for its assessment, and a review of research is necessary. This systematic review focuses on ICD-11 CPTSD assessment in young people aged 7 to 17 and adults aged 18 and above, examining measures, differentiating features and clinical considerations. Data from five databases are reviewed using a narrative synthesis approach and the quality of evidence is assessed and discussed. A total of 36 studies involving 5901 participants recruited from clinical settings and 1458 professionals with CPTSD assessment experience were included. Studies predominantly focused on adults, and the most used measure for assessment was the International Trauma Questionnaire. Papers focusing on differentiating features highlighted increased symptom severity, impairment and difficulties in individuals with CPTSD, compared to those with PTSD across various characteristics in both young people and adults. This review also identified the importance of a sensitive clinical approach with adaptations based on culture and age. Although gold-standard recommendations cannot be made, this paper offers tentative clinical practice recommendations and considerations regarding ICD-11 CPTSD assessment.

Trauma-focused treatment of a client with Complex PTSD and comorbid pathology using EMDR therapy

OBJECTIVE

Complex post-traumatic stress disorder (CPTSD) is a classification within the International Classification of Diseases, 11th Revision (ICD-11) that, besides the DSM-5 symptom clusters of post-post-traumatic stress disorder (PTSD), includes the presence of negative self-concept, difficulties in regulating emotions and relationship skills. The purpose of the present study was to provide guidance on how to deliver Eye Movement Desensitization and Reprocessing (EMDR) therapy in the context of CPTSD, based on current clinical knowledge and the latest scientific research findings.

METHOD

This paper describes the treatment of a 52-year-old woman with CPTSD and borderline personality disorder for which immediate trauma-focused EMDR therapy was used.

RESULTS

First, a description of what EMDR therapy entails and some important treatment strategies that the therapist may employ to assist in trauma-focused treatment of clients with CPTSD using EMDR therapy are outlined.

CONCLUSION

The treatment results are in line with mounting evidence supporting the notion that EMDR therapy is a safe and potentially effective treatment alternative for individuals with CPTSD or personality problems.

A network analysis of ICD-11 Complex PTSD, emotional processing, and dissociative experiences in the context of psychological trauma at different developmental stages

Objective

Traumatic experiences are a significant risk factor for psychological disturbances, including disorders such as complex posttraumatic stress disorder, emotion-processing problems, and trauma-related dissociative experiences. The present investigation examined the coexistence of these symptoms using a network analysis model.

Method

This study included a sample of 406 people referred to comprehensive health centers in Tehran from September to December 2023 with psychopathological syndromes. Variables were assessed using The International Trauma Questionnaire, International Measurement of Exposure to Traumatic Event checklist, Baker Emotional Processing Questionnaire, and Dissociative Experiences. A regularized partial correlation network and Glasso algorithm, in combination with Extended Bayesian information criteria, were applied to estimate the network structure.

Results

Signs of unprocessed emotions and disturbance in self-organization symptoms were the most important symptoms in the symptom network, forming strong connections with other nodes. Thereby, these two symptoms can be regarded as the most important clinical manifestations in the symptom network following traumatic experiences. Three distinct symptom communities were identified: the community of traumatic experiences (childhood, adolescence, adulthood), the community of dissociative experiences (amnesia, depersonalization/derealization, and absorption), and the community of emotional processing (suppression, unpleasant emotional experience, Signs of unprocessed emotions, avoidance, and emotional control, posttraumatic stress disorder symptoms and disturbance in self-organization symptoms). The strongest edges observed were between childhood trauma-adolescence trauma (0.473) in the community of traumatic experiences, between amnesia and depersonalization/derealization (0.644) in the community of dissociative experiences, and between disturbance in self-organization symptoms and unprocessed emotions (0.324) in the community of emotional processing, indicating the recurrent occurrence of these symptoms.

Conclusion

In this study, disturbance in self-organization symptoms was identified as the central psychopathologic symptom in individuals experiencing traumas at different developmental stages. It seems that adolescent trauma and not childhood trauma plays a more decisive role in the symptoms that a person manifests after traumatic experiences. Also, posttraumatic stress disorder symptoms and disturbance in self-organization symptoms were recognized in the cluster of emotional processing symptoms and can have substantial roles in prioritizing therapeutic measures.

Components of event-related potentials and borderline personality disorder: a meta-analysis

Background: Borderline personality disorder (BPD) is characterized by symptoms associated with difficulties in emotion regulation, altered self-image, impulsivity, and instability in personal relationships. A relationship has been found between BPD symptoms and altered neuropsychological processes. Studies of event-related potentials (ERP) measured with electroencephalogram (EEG) have found neural correlates related to BPD symptoms. Of note is the P300 component, considered a potential mental health biomarker for trauma-associated disorders. However, no meta-analysis has been found to demonstrate this relationship.Objectives: To evaluate the relationship between the P300 component and BPD symptoms. To evaluate the relationship of other ERP components with BPD symptoms.Methods: The method and procedure were adjusted to the PRISMA checklist. The search was performed in three databases: WOS, Scopus and PubMed. A Random Effects Model was used to perform the analysis of the studies. In addition, a meta-regression was performed with % women, Gini and GDP. Finally, a descriptive analysis of the main results found between P300, other ERP components (LPP, P100 and ERN/Ne) and BPD symptoms was performed.Results: From a review of 485 articles, a meta-analysis was performed with six articles that met the inclusion criteria. A moderate, positive relationship was found between the P300 component and BPD symptoms (REM = .489; p < .001). It was not possible to perform meta-analyses for other ERP components (LPP, P100 and ERN/Ne) due to the low number of articles found.Conclusion: The idea that P300 could be considered for use as a biomarker to identify altered neural correlates in BPD is reinforced. In addition, a moderating effect of inequality (Gini) was detected.

Childhood maltreatment, dissociation and borderline personality disorder: Preliminary data on the mediational role of mentalizing in complex post-traumatic stress disorder

OBJECTIVES

Treatments for borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) are less effective for patients with co-occurring symptoms of both disorders, who are considered to have complex PTSD (cPTSD), compared with patients with either condition alone. Evidence suggests that co-occurrence of symptoms indicates greater impairment in mentalizing. This study examines evidence for targeting mentalizing when treating individuals with co-occurring symptoms, irrespective of their exposure to developmental trauma and, for the first time, investigates the mediational role of mentalizing in the associations between BPD symptomatology and cPTSD.

DESIGN

We identified in a routine clinical service a group of patients with BPD, with or without co-occurring symptoms of PTSD. We hypothesized that patients with co-occurring symptoms and a history of childhood maltreatment will show more severe clinical profiles and greater mentalizing problems, which in turn lead to symptoms consistent with cPTSD.

METHOD

Clinical profiles of 72 patients with BPD (43 with and 29 without co-occurring symptoms of PTSD; mean age in both groups 28 years, 79% and 83% female, respectively) were identified using the Structured Clinical Interview for DSM-IV Axis II Disorders. Patients completed self-report measures of BPD and PTSD symptoms, well-being, dissociation and reflective functioning. Childhood trauma histories were evaluated.

RESULTS

Compared with patients with BPD-only, those with co-occurring BPD and PTSD showed greater severity in terms of BPD and dissociative symptoms, met a broader range of BPD diagnostic criteria, had a greater sense of personal worthlessness and self-evaluated their well-being as considerably diminished. This group was also more inclined to recall increased instances of childhood sexual abuse. In a mediation analysis, mentalizing acted as a partial mediator for the relationship between BPD severity and cPTSD, as well as between dissociative symptoms and cPTSD. Interestingly, mentalizing did not mediate the relationship between childhood sexual abuse and cPTSD.

CONCLUSIONS

Overall, the correlational findings are consistent with an intended focus on mentalizing to treat cPTSD symptoms in individuals who also meet criteria for a diagnosis of BPD.

ICD-11 complex posttraumatic stress disorder and subclasses of borderline personality disorder in a South Korean adult population with childhood abuse experiences: a latent class analysis

BACKGROUND

Complex posttraumatic stress disorder (CPTSD) and borderline personality disorder (BPD), which are distinctive diagnoses, share the common risk factor of childhood abuse experiences. However, additional evidence is needed to determine which factors contribute to the manifestation of different symptoms.

METHOD

Participants were 499 South Korean early and midlife adults with primarily college level education who reported experiences of childhood abuse. They were enrolled from an online panel using a stratified sampling considering gender, age, and residence information. A latent class analysis (LCA) was conducted to identify the patterns of CPTSD and BPD symptoms. We adopted a three-step LCA to compare types of childhood abuse, invalidating environments, attachment styles, and pathological personality traits among different classes.

RESULTS

The LCA revealed four classes. Class 1 showed the highest scores in all symptoms and risk factors. Class 2 was distinguished from Class 3 by the externalizing versus internalizing associated pathological personality traits. Class 3 experienced high emotional neglect in addition to other types of abuse and it also showed an additional avoidant attachment style. Class 4 showed low symptomatology.

CONCLUSION

Class 1 was named as a CPTSD and BPD "comorbid" class, Class 2 as an "externalizing BPD" class, Class 3 as an "avoidant BPD" class, and Class 4 as a "low symptom" class. Childhood abuse may heighten the risk for high comorbidity of CPTSD and BPD as well as externalizing-internalizing subgroups of BPD. Beyond the identification of CPTSD and BPD, assessing attachment styles and pathological personality traits based on dimensional approaches would benefit the tailoring of effective treatment.

Distinguishing between ICD-11 complex post-traumatic stress disorder and borderline personality disorder: clinical guide and recommendations for future research

Although complex post-traumatic stress disorder and borderline personality disorder are distinct disorders, there is confusion in clinical practice regarding the similarities between the diagnostic profiles of these conditions. We summarise the differences in the diagnostic criteria that are clinically informative and we illustrate these with case studies to enable diagnostic accuracy in clinical practice.

Effects of Maternal Separation and Subsequent Stress on Behaviors and Brain Monoamines in Rats

Childhood adversity can induce maladaptive behaviors and increase risk for affective disorders, post-traumatic stress disorder, personality disorders, and vulnerability to stress in adulthood. Deprivation of maternal care interrupts brain development through the disturbance of various neurotransmitters, however, the details remain unclear. The features of the symptoms of disorders are largely determined by early stress protocol, genetic characteristics (line), and the sex of the animals. The purpose of current study was (1) to assess behavioral changes in adult Wistar rats of both sexes after early life stress; (2) to determine the levels of monoamines in brain structures involved in the motor, emotional, and social reactions in rats aged 1 and 2 months; and (3) to determine the level of monoamines after physical or emotional stress in adult rats. The rat pups were separated from their dams and isolated from siblings in tight boxes at a temperature of 22-23 °C for 6 h during postnatal days 2-18. The data were processed predominantly using two-way analysis of variance and the Newman-Keys test as the post hoc analysis. The adult rats demonstrated an increase in motor activity and aggressiveness and a decrease in levels of anxiety and sociability. Behavioral disturbances were accompanied by region-, sex-, and age-dependent changes in the levels of monoamines and their metabolites. The dopaminergic and noradrenergic systems were found to be sensitive to psycho-emotional stress.