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What is the link between PTSD, BPD and Bi-Polar?

Q: Dear Frank, Here's a question recently asked on Gift From Within's Facebook page: "Please explain to me the links between PTSD and Borderline Personality Disorder and/or Bi-Polar. Can having PTSD lead to the others? Or does the fact hat you had one or both of the others (undiagnosed) mean that you were more likely to get PTSD?"

A: Dear Joyce, Not too long ago, I was asked to explain Borderline Personality Disorder. Here's that explanation:

Dear Joyce, Diagnoses, particularly personality disorder diagnoses, tend to pigeon-hole people and diminish their complexity and humanity. Borderline Personality Disorder (BPD) certainly has been used by some mental health professionals to label rather than to explain. Let me do my best to explain what is intended and what can be learned about this complicated condition. First, borderline was intended, almost half a century ago, to be the boundary between psychosis and neurosis. Some people were observed to have difficulty managing anxiety (neurosis), but they also lost touch with reality (psychosis) when extremely distressed. Unlike persons suffering from schizophrenia or bipolar disorder, they were usually free of prolonged episodes of disordered thinking or of mood fluctuations. But they often had relatives who were diagnosed with these disorders (schizophrenia; bipolar). So some psychiatric researchers, particularly those who focused on biological issues, believed "borderline" was linked genetically to the spectrum of major disorders of thought and mood. Some "borderlines" are also "bipolar," less frequently, "schizophrenic."

Second, borderline, or BPD, appears to be driven by problems of attachment to the mother, beginning in late infancy or early childhood. The very first criterion for giving the diagnosis is "frantic efforts to avoid real or imagined abandonment." Therapists who follow Freudian and similar theories look for significant events in the early stages of life, formative events, and they place great weight on such life-shaping experiences.

In the case of BPD, these therapists believe that the little child, one and one half years to three years old, was separated, physically or emotionally from the mother, and there were no other sources of reliable comfort available. The child felt abandoned. The emotion was one of extreme fear and it turned into rejection of the mother. With child-reason, full of fantasy, the youngster began a fruitless search for ideal protectors (guardian angels) and became vulnerable to the second criterion of BPD: "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation." I have been on the receiving end of this pattern, admired beyond reason then reviled with rage. Most therapists understand and tolerate borderline emotion, realizing it is based on child-like reason. Most unfortunately, this condition includes feeling dead inside. Some people with BPD will cut themselves, not because they are suicidal, but because they want to feel something real. Physical pain is, on occasion, preferable to feeling dead. Persons with BPD are confused about who they are and what their life really means.

Because BPD includes such intense emotion, interpersonal relationships are roller-coaster affairs and are very confusing, sometimes infuriating, to the partner. Violent abuse or insensitive rejection follows. Persons with BPD are often victims of trauma.

From the perspective of the therapist, this is a real challenge. Warmth and collegiality are misinterpreted as deep, personal friendship or as sexual signals. It is a mistake for a therapist to encourage anything but a professional relationship when treating a person with BPD. You have to keep boundaries clear with a borderline person.

It just helps to know that our biology and our earliest experiences may make us exquisitely sensitive to rejection from a parent-like person, setting us on a very difficult path of being drawn to such persons, seeking love in all the wrong places, then causing us to turn on the person we were once attracted to --attracted to for reasons that have more to do with our infancy than with current reality.

I've also described Complex PTSD in previous Gift From Within postings:

Dear Joyce, Complex PTSD is a concept first defined by Judith Herman, MD (see http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp) to account for the effects of prolonged, severe interpersonal stress. She was thinking about cases in which a person is captured and humiliated or is sexually victimized within the family. But it is true of victims of war and victims of household war: battered spouses. When emotional trauma is continuous and inescapable, the mind and body adapts in several ways, from stoic to tragic. People can "zone out" or, technically, dissociate. They experience an altered state of consciousness. This might, in extreme cases, develop into multiple personalities. People can abandon hope. Without yearning for dignity and freedom, they accept psychological slavery. People can love their abusers. This is called Stockholm Syndrome (see http://www.giftfromwithin.org/html/stockhlm.html).

The therapy for oppression is different than the therapy for simple PTSD. It requires moving to a safe environment. It requires retraining survival instincts, once there is no real danger. The medication may be similar (anti-depressants, tranquilizers, sedatives) but medication is never enough. And therapy is never enough. It takes liberation and love and plenty of patience to emerge from complex PTSD.

So you can see that some people develop both BPD and complex PTSD from childhood abuse. Bipolar disorder used to be called Manic-Depressive disorder. By definition, there must be significant periods of low moods and of high moods. The highs can be rather enjoyable but they can also be dangerous with terrible judgment, leading to loss of money, dignity or life. The lows can be miserable, feeling helpless, hopeless and worthless. Lows tend to last several weeks or months. Highs tend to last several days. In unusual cases, both highs and lows occur at once. This is a medical emergency and should be treated without delay. In my opinion, Bipolar disorder is a brain disease that runs in families, is due primarily to an inherited pre-disposition and is not caused by trauma. Trauma may precipitate an episode. There certainly are people who have Borderline Personality Disorder and also have Bipolar disorder. If they suffer a major trauma later in life, say a violent assault, they could have PTSD as well. The trauma could bring on a depressive or a manic episode. The trauma could cause a delusion or hallucinations (a psychotic episode) in someone with BPD. Having BPD means the person is predisposed to psychotic episodes when traumatized. So if you had one or both (undiagnosed Bipolar and Borderline disorders) you are more likely to have symptoms that resemble PTSD. You are more likely to encounter trauma if depressed. The trauma is more likely to lead to PTSD if you are depressed. The combination of PTSD and depression is often seen. So all three conditions are inter-related. But an adult trauma does not cause Borderline Personality Disorder. BPD is a long term condition, diagnosed in early adulthood, but originating much earlier in life.

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