Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis

Abstract

Background: There has been debate regarding whether Complex Posttraumatic Stress Disorder (Complex PTSD) is distinct from Borderline Personality Disorder (BPD) when the latter is comorbid with PTSD.

Objective: To determine whether the patterns of symptoms endorsed by women seeking treatment for childhood abuse form classes that are consistent with diagnostic criteria for PTSD, Complex PTSD, and BPD.

Method: A latent class analysis (LCA) was conducted on an archival dataset of 280 women with histories of childhood abuse assessed for enrollment in a clinical trial for PTSD.

Results: The LCA revealed four distinct classes of individuals: a Low Symptom class characterized by low endorsements on all symptoms; a PTSD class characterized by elevated symptoms of PTSD but low endorsement of symptoms that define the Complex PTSD and BPD diagnoses; a Complex PTSD class characterized by elevated symptoms of PTSD and self-organization symptoms that defined the Complex PTSD diagnosis but low on the symptoms of BPD; and a BPD class characterized by symptoms of BPD. Four BPD symptoms were found to greatly increase the odds of being in the BPD compared to the Complex PTSD class: frantic efforts to avoid abandonment, unstable sense of self, unstable and intense interpersonal relationships, and impulsiveness.

Conclusions: Findings supported the construct validity of Complex PTSD as distinguishable from BPD. Key symptoms that distinguished between the disorders were identified, which may aid in differential diagnosis and treatment planning.

CLINICAL RESEARCH ARTICLE

Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis

Marylène Cloitre1,2*, Donn W. Garvert1, Brandon Weiss1,3, Eve B. Carlson1 and Richard A. Bryant4

1National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA; 2Department of Psychiatry and Child & Adolescent Psychiatry, New York University Medical Center, New York, USA; 3Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA; 4School of Psychology, University of New South Wales, Sydney, NSW, Australia

Abstract

Background : There has been debate regarding whether Complex Posttraumatic Stress Disorder (Complex PTSD) is distinct from Borderline Personality Disorder (BPD) when the latter is comorbid with PTSD.

Objective : To determine whether the patterns of symptoms endorsed by women seeking treatment for childhood abuse form classes that are consistent with diagnostic criteria for PTSD, Complex PTSD, and BPD.

Method : A latent class analysis (LCA) was conducted on an archival dataset of 280 women with histories of childhood abuse assessed for enrollment in a clinical trial for PTSD.

Results : The LCA revealed four distinct classes of individuals: a Low Symptom class characterized by low endorsements on all symptoms; a PTSD class characterized by elevated symptoms of PTSD but low endorsement of symptoms that define the Complex PTSD and BPD diagnoses; a Complex PTSD class characterized by elevated symptoms of PTSD and self-organization symptoms that defined the Complex PTSD diagnosis but low on the symptoms of BPD; and a BPD class characterized by symptoms of BPD. Four BPD symptoms were found to greatly increase the odds of being in the BPD compared to the Complex PTSD class: frantic efforts to avoid abandonment, unstable sense of self, unstable and intense interpersonal relationships, and impulsiveness.

Conclusions : Findings supported the construct validity of Complex PTSD as distinguishable from BPD. Key symptoms that distinguished between the disorders were identified, which may aid in differential diagnosis and treatment planning.

Keywords: Complex PTSD; posttraumatic stress disorder; Borderline Personality Disorder; WHO; ICD-11

*Correspondence to: Marylène Cloitre, National Center for PTSD Dissemination and Training Division, VAPAHCS, 795 Willow Road, Menlo Park, CA 94025, USA, Email: [email protected]

For the abstract or full text in other languages, please see Supplementary files under Article Tools online

Received: 3 June 2014; Revised: 22 July 2014; Accepted: 18 August 2014; Published: 15 September 2014

European Journal of Psychotraumatology 2014. © 2014 Marylène Cloitre et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 Unported (CC BY 4.0) License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license is provided, and that you indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

Citation: European Journal of Psychotraumatology 2014, 5 : 25097 - http://dx.doi.org/10.3402/ejpt.v5.25097

There has long been debate about whether Complex Posttraumatic Stress Disorder (Complex PTSD) is distinct from Borderline Personality Disorder (BPD) comorbid with PTSD. Part of the difficulty in this evaluation has been the lack of clear and consistent characterization of Complex PTSD. The World Health Organization (WHO) Working Group on the Classification of Stress-Related Disorders has proposed the inclusion of Complex PTSD as a new diagnosis related to but separate from PTSD (Maercker et al., 2013). Both of these disorders are viewed as distinct and separate from BPD. An emerging and accumulating empirical literature is demonstrating consistent and clear differences between ICD-11 PTSD and Complex PTSD. In addition, it is important to determine the construct validity of Complex PTSD as empirically distinct from BPD particularly among those with a trauma history. This investigation evaluated whether ICD-11 Complex PTSD could be distinguished from DSM-IV BPD in a treatment-seeking population of women with childhood abuse.

The WHO proposed that the development of ICD-11 be guided by the principle of clinical utility. Characteristics of clinical utility include the organization of disorders that are consistent with clinicians' mental health taxonomies, that contain a limited number of symptoms so that they can be easily recalled and used in the field, and that are based on distinctions important for management and treatment (Reed, 2010). The distinction between ICD-11 PTSD and Complex PTSD are consistent with these guidelines (see Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; Maercker et al., 2013). For example, ICD-11 PTSD is construed as a fear-based disorder and symptoms are limited to and consistent with fear reactions and consequent avoidance and hypervigilence. In contrast, Complex PTSD has been described as typically associated with chronic and repeated traumas and includes not only the symptoms of PTSD but also disturbances in self-organization reflected in emotion regulation, self-concept and relational difficulties (see Cloitre et al., 2013) a symptom profile that has been demonstrated as associated with prolonged trauma (Briere & Rickards, 2007).

Three studies have found evidence supporting the validity of the ICD-11 PTSD versus Complex PTSD distinction (see Table 1 for description of the diagnoses). Recently, in order to evaluate whether PTSD and Complex PTSD could be empirically distinguished from each other, Cloitre and colleagues (2013) performed a latent profile analysis (LPA) on assessment data from 302 treatment-seeking individuals with diverse trauma histories, ranging from single events (e.g., 9/11 attacks) to sustained exposures (e.g., childhood or adult physical and/or sexual abuse). The results were consistent with the ICD-11 formulation for Complex PTSD, with the best fitting LPA model delineating three classes of individuals: (1) a Complex PTSD class, with high levels of both PTSD symptoms as well as disturbances in self-organization related to affect regulation problems, negative self-concept, and relational difficulties; (2) a PTSD class, with high levels of PTSD symptoms but relatively low on the disturbances in self-organization that define Complex PTSD; and (3) a class relatively low on symptoms of both PTSD and Complex PTSD. Notably, these identified classes were identical when including an additional 86 participants with BPD, providing further support for the stability of the identified classes. Cloitre et al. (2013) also found that chronic trauma was more predictive of Complex PTSD than PTSD and that Complex PTSD resulted in significantly greater functional impairment than PTSD.

[Table omitted -see PDF.]

CI=Confidence Interval.

*p <0.01.

Interpretation example: Individuals positive on the Frantic symptom had a 2.95 times greater risk of being in the BPD class than those without the Frantic symptom.

Discussion

Overall, the findings showed that the patterns of symptoms endorsed formed classes that are consistent with diagnostic criteria for PTSD, Complex PTSD, and BPD. The LCA identified four distinct classes of individuals within a treatment-seeking sample: a Low Symptom class that was relatively low in all measured symptoms; a PTSD class that was high in symptoms of PTSD but relatively low in self-organization symptoms and symptoms of BPD; a Complex PTSD class that was high in symptoms of PTSD and self-organization symptoms but relatively low in symptoms of BPD; and a BPD that was high in symptoms of BPD with additional symptoms of PTSD and CPTSD. These distinct classes demonstrated acceptable discrimination. Additionally, these classes did not differ in demographic variables (e.g., age, ethnicity, employment status) or total number of traumas experienced. These findings provide empirical support that the symptom profiles endorsed by individuals with Complex PTSD and BPD result in distinguishable subgroups of trauma-exposed individuals.

While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them.

It should be noted that the endorsement of the CPTSD symptoms related to self-organization disturbances was high among members of the BPD class. It may be that the presence emotion regulation problems does not distinguish CPTSD and BPD, although the severity and type might, i.e., suicidality, self-injurious behavior are characteristic of BPD not CPTSD. Alternatively, it may be that the BSI is not optimal as a measure of self-organization disturbances to provide differential diagnosis of CPTSD versus BPD. The BSI tracks symptoms only for the past 2 weeks, and thus chronicity of symptoms was not assessed. Members of the BPD class may have some but not all of the CPTSD symptoms and may vary in their endorsement of symptoms across time while the symptoms as endorsed by the CPTSD class would be expected to be chronic and stable. This interpretation is consistent with the data from the SCID-II questions where items highlighting lack of stability were strongly endorsed by the BPD but not the CPTSD and PTSD class members.

Overall, the findings indicate that there are several ways in which Complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation. Lastly, a comment on the Low Symptom class is deserved. The class seems comprised of individuals who have very low endorsement of PTSD symptoms but somewhat higher endorsements on disturbances in self-organization. These symptoms may reflect the presence of subsyndromal BPD or symptoms resulting from a mix other Axis I disorders (Bipolar Disorder, Major Depression). Future studies, which evaluate Axis I disorders and provide subsyndromal diagnoses, will help decipher the nature of this class.

The distinct symptom profiles characterizing CPTSD and BPD lead to different treatment considerations. The focus of treatment for BPD concerns reduction of life-interfering behaviors such as suicidality and self-injurious behaviors, a reduction in dependency on others and an increase in an internalized and stable sense of self (e.g., Dialectical Behavior Therapy, Linehan, 1993). In contrast, treatment programs for CPTSD focus on reduction of social and interpersonal avoidance, development of a more positive self-concept and relatively rapid engagement in the review and meaning of traumatic memories (e.g., Cloitre et al., 2006). Duration of treatment for each disorder and attention to the termination phase are different as well. Experts in the treatment of BPD have noted that the termination of treatment is a time of risk for relapse and symptom exacerbation (see Harned & Linehan, 2008). The end of therapy may provoke feelings of abandonment, destabilize identity and lead to impulsive and self-injurious behaviors. The DSM guidelines for BPD recommend treatment duration of at least 1 year (American Psychiatric Association, 2013). A treatment course of a year or more may allow for demonstrated success in reduction of life-interfering behaviors, the reinforcement and routinization of effective emotion management skills and a carefully planned end to treatment. While the recommended duration of treatment for Complex PTSD has not yet been established, it seems likely be shorter than for BPD given the presence of a stable sense of self and relative absence of substantial risk for self-injurious behaviors and suicidality, but longer than that for PTSD, given the greater number and diversity of symptoms (see Cloitre et al., 2012).

Growing attention to patient-centered care, which emphasizes the patient's specific symptoms, needs and preferences will hopefully facilitate the development of treatment programming that neither under-treats nor over-treats the patient. The proposed spectrum of diagnoses moving from PTSD to CPTSD and BPD may provide a foundation for developing algorithms of type of interventions and duration of care that meets the needs of patients with symptom profiles that differ in clinically significant ways.

A number of limitations of the current study are worth noting. First, the sample consisted of a treatment-seeking sample with a history of childhood interpersonal trauma. Replication of results is necessary with samples that are more representative of populations in clinical and community settings. Future studies should include samples with greater diversity in types of trauma as well as diversity in the exposure to traumatic stressors. Secondly, the data used in the analyses are from a secondary source and do not represent the ideal basis for evaluating ICD-11 PTSD and Complex PTSD symptoms. The Structured Interview for Disorders of Extreme Stress (SIDES, Pelcovitz et al., 1997), a structured clinician driven measure which assesses many of the symptoms of Complex PTSD was not available in this data set. Also, the time duration for which the symptoms were assessed differed across measures and thus did not allow consistency in the assessment of the chronicity or variability of the symptoms endorsed. However, the study results, which provide evidence of qualitative differences between the CPTSD and BPD symptom profiles, suggest the importance of developing empirically validated measures of ICD-11 PTSD and CPTSD and their comparison to BPD in a variety of clinical and epidemiological samples.

Conclusion

This study identified four distinct classes of individuals who have experienced trauma, supporting the proposed distinction between Complex PTSD and BPD. Key symptoms that differentiate BPD from Complex PTSD were identified. These findings conform to ICD-11's proposed distinction between the diagnoses. They also point to the merits of pursuing the construct of CPTSD as a separate clinical entity from PTSD and BPD. However, to achieve this agenda it is important that empirically validated measures of CPTSD be developed for standardized assessment of the construct in relation to PTSD and BPD. Given that that there are efficacious treatments for CPTSD (Cloitre et al., 2010) and BPD (e.g., Linehan, 1993), and these approaches vary in important ways, it is useful for clinicians to be able to differentiate between these presentations.

Disclaimer

M Cloitre and R Bryant are members of the WHO of the Working Group on the Classification of Stress-Related Disorders. However, the views expressed reflect the opinions of the authors and not necessarily the Working Group and the content of this manuscript does not represent WHO policy.

Conflict of interest and funding

There is no conflict of interest in the present study for any of the authors. This manuscript was supported by a National Institute of Mental Health grant, RO1 MH-062347 to the first author (M. Cloitre).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Briere, J., & Rickards, S. (2007). Self-awareness, affect regulation, and relatedness: Differential sequels of childhood versus adult victimization experiences. Journal of Nervous and Mental Disease , 195 , 497-503. PubMed Abstract | Publisher Full Text

Cloitre, M., Cohen, L., & Koenan, K. (2006). Treating survivors of childhood abuse: psychotherapy for the interrupted life . New York: Guilford Press.

Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L., Alexander, P., Briere, J., et al. (2012). The ISTSS expert consensus treatment guidelines for complex PTSD in adults. Retrieved May 13, 2014, from http://www.istss.org/

Cloitre, M., Courtois, C. C., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Breen, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress , 24 , 616-627. Publisher Full Text

Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology , 4 , 20706, doi: http://dx.doi.org/10.3402/ejpt.v4i0.20706 Publisher Full Text

Cloitre, M., Stovall-McClough, C. K., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L., et al. (2010). Treatment of PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry , 167 , 915-924. PubMed Abstract | Publisher Full Text

Derogatis, L. R., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report. Psychological Medicine , 13 , 595-605. PubMed Abstract | Publisher Full Text

Elklit, A., Hyland, P. & Shevlin, M. (2014). Evidence of symptom profiles consistent with posttraumatic stress disorder and complex posttraumatic stress disorder in different trauma samples. European Journal of Psychotraumatology , 5 , 24221, doi: http://dx.doi.org/10.3402/ejpt.v5.24221 Publisher Full Text

First, M. D., Spitzer, M. D., Gibbon, M., & Williams, J. W. (1994). Structured Clinical Interview for DSM-IV , Patient Edition. New York: Biometrics Research Department, New York State Psychiatric Institute.

Golier, J. A., Yehuda, R., Bierer, L. M., Mitropoulou, V., New, A. S., Schmeidler, J., et al. (2003). The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. American Journal of Psychiatry , 160 , 2018-2024. PubMed Abstract | Publisher Full Text

Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the wave 2 national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry , 69 , 533-545. PubMed Abstract | PubMed Central Full Text | Publisher Full Text

Harned, M. S., & Linehan, M. M. (2008). Integrating dialectical behavior therapy and prolonged exposure to treat co-occurring borderline personality disorder and PTSD: Two case studies. Cognitive and Behavioral Practice , 15 , 263-276. Publisher Full Text

Harned, M. S., Rizvi, S. L., & Linehan, M. M. (2010). The impact of co-occurring posttraumatic stress disorder on suicidal women with borderline personality disorder. American Journal of Psychiatry , 167 , 1210-1217. PubMed Abstract | Publisher Full Text

Heffernan, K., & Cloitre, M. (2000). A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: Etiological and clinical characteristics. Journal of Nervous and Mental Disease , 188 , 589-595. PubMed Abstract | Publisher Full Text

Knefel, M., & Lueger-Schuster, B. (2013). An evaluation of ICD-11 PTSD and complex PTSD criteria in a sample of adult survivors of childhood institutional abuse. European Journal of Psychotraumatology , 4 , 22608, doi: http://dx.doi.org/10.3402/ejpt.v4i0.22608 Publisher Full Text

Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder . New York: Guilford Press.

Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., Reed, G. M., Van Ommeren, M., et al. (2013). Proposals for mental disorders specifically associated with stress in the ICD-11. Lancet , 381 (9878), 1683-1685. doi: 10.1016/S0140-6736(12)62191-6. PubMed Abstract | Publisher Full Text

Nylund, K. L., Asparouhov, T., & Muthen, B. O. (2007). Deciding on the number of classes in latent class analysis and growth mixture modelling: A Monte Carlo simulation study. Structural Equation Modeling , 14 (4), 535-569. Publisher Full Text

Pagura, J., Stein, M. B., Bolton, J. M., Cox, B. J., Grant, B., & Sareen, J. (2010). Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. Journal of Psychiatric Research , 44 , 1190-1198. PubMed Abstract | Publisher Full Text

Pelcovitz, D., Van der Kolk, B., Roth, S., Mandel, F., Kaplan, S., & Resick, P. (1997). Development of a criteria set and a structured interview for disorders of extreme stress (SIDES). Journal of Traumatic Stress , 10 , 3-17. PubMed Abstract

Reed, G. M. (2010). Toward ICD-11: Improving the clinical utility of WHO's international classification of mental disorders. Professional Psychology: Research and Practice , 41 , 457-464. Publisher Full Text

Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-Administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety , 13 , 132-156. PubMed Abstract | Publisher Full Text

Weissman, E., & Bothell, S. (1976). Assessment of patient social adjustment by patient self-report. Archives of General Psychiatry , 33 , 1111-1115. PubMed Abstract | Publisher Full Text

Zanarini, M. C., Frankenburg, F. R., Dubo, E. D., Sickel, A., Trikha, A., Levin, A., et al. (1998). Axis I comorbidity of borderline personality disorder. American Journal of Psychiatry , 155 , 1733-1739. PubMed Abstract

Zlotnick, C., Franklin, C. L., & Zimmerman, M. (2002). Is comorbidity of posttraumatic stress disorder and borderline personality disorder related to greater pathology and impairment? American Journal of Psychiatry , 159 , 1940-1043. PubMed Abstract | Publisher Full Text