Background: Traditionally, the presence of post-traumatic stress disorder (PTSD) in subjects diagnosed with borderline personality disorder (BPD) has been the object of scant empirical research. The clarification of issues related to the different areas of study for this comorbidity is not only significant from a theoretical point of view but also relevant for clinical practice. The aim of this review is to describe the main theoretical findings and research conclusions about the comorbidity between PTSD and BPD. Methods: A literature review was carried out via PubMed and PsycINFO for the period between 1990 and September 2013. The descriptors used were ‘post-traumatic stress disorder', ‘borderline personality disorder', ‘PTSD', ‘complex PTSD' and ‘BPD'. Results: Epidemiological studies show that the risk of PTSD among BPD subjects is not regularly higher than in subjects with other personality disorders. Furthermore, there is no conclusive evidence about the main aetiopathogenic mechanism of this comorbidity, either of one disorder being a risk factor for the other one or of common underlying variables. Concerning comparative studies, several studies with PTSD-BPD subjects have found a higher severity of psychopathology and psychosocial impairment than in BPD subjects. With regard to nosological status, the main focus of controversy is the validation of ‘complex PTSD', a clinical entity which may comprise a subgroup of PTSD-BPD subjects. With regard to treatment, there are preliminary evidences for the efficient treatment of psychopathology in both PTSD and BPD. Conclusions: These findings are remarkable for furthering the understanding of the link between PTSD and BPD and their implications for treatment. The results of this review are discussed, including methodological constraints that hinder external validity and consistency of referred findings.

1.
Gunderson JG, Sabo AN: The phenomenological and conceptual interface between borderline personality disorder and PTSD. Am J Psychiatry 1993;150:19-27.
2.
Herman J: Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. J Trauma Stress 1992;5:377-391.
3.
Weniger G, Lange C, Sachsse U, Irle E: Reduced amygdala and hippocampus size in trauma-exposed women with borderline personality disorder and without posttraumatic stress disorder. J Psychiatry Neurosci 2009;34:383-388.
4.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:617-627.
5.
Perrin M, Vandeleur CL, Castelao E, Rothen S, Glaus J, Vollenweider P, Preisig M: Determinants of the development of post-traumatic stress disorder, in the general population. Soc Psychiatry Psychiatr Epidemiology 2014;49:447-457.
6.
Pietrzak RH, Goldstein RB, Southwick SM, Grant BF: Personality disorders associated with full and partial posttraumatic stress disorder in the U.S. population: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Psychiatr Res 2011;45:678-686.
7.
Pagura J, Stein MB, Bolton JM, Cox BJ, Grant B, Sareen J: Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. J Psychiatr Res 2010;44:1190-1198.
8.
Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A, Reynolds V: The axis I comorbidity of borderline personality disorder. Am J Psychiatry 1998;155:1733-1739.
9.
Zimmerman MJ: Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry 1999;40:245-252.
10.
Amstadter AB, Aggen SH, Knudsen GP, Reichborn-Kjennerud T, Kendler KS: Potentially traumatic event exposure, posttraumatic stress disorder, and axis I and II comorbidity in a population-based study of Norwegian young adults. Soc Psychiatry Psychiatr Epidemiol 2013;48:215-223.
11.
Sack M, Sachsse U, Overkamp B, Dulz B: Trauma-related disorders in patients with borderline personality disorders. Results of a multicenter study (in German). Nervenarzt 2013;84:608-614.
12.
Schredl M, Paul F, Reinhard I, Ebner-Priemer UW, Schmahl C, Bohus M: Sleep and dreaming in patients with borderline personality disorder: a polysomnographic study. Psychiatry Res 2012;200:430-436.
13.
Spitzer C, Effler K, Freyberger HJ: Posttraumatic stress disorder, dissociation and self-destructive behavior in borderline patients (in German). Z Psychosom Med Psychother 2000;46:273-285.
14.
Van Den Bosch LM, Verheul R, Langeland W, Van Den Brink W: Trauma, dissociation, and posttraumatic stress disorder in female borderline patients with and without substance abuse problems. Aust NZ J Psychiatry 2003;37:549-555.
15.
Zanarini MC, Hörz S, Frankenburg FR, Weingeroff J, Reich DB, Fitzmaurice G: The 10-year course of PTSD in borderline patients and axis II comparison subjects. Acta Psychiatr Scand 2011;124:349-356.
16.
Golier JA, Yehuda R, Bierer LM, Mitropoulou V, New AS, Schmeidler J, Silverman JM, Siever LJ: The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. Am J Psychiatry 2003;160:2018-2024.
17.
Dunn NJ, Yanasak E, Schillaci J, Simotas S, Rehm LP, Souchek, J, Menke T, Ashton C, Hamilton JD: Personality disorders in veterans with posttraumatic stress disorder and depression. J Trauma Stress 2004;17:75-82.
18.
Yen S, Shea MT, Battle CL, Johnson DM, Zlotnick C, Dolan-Sewell R, Skodol AE, Grilo CM, Gunderson JG, Sanislow CA, Zanarini MC, Bender DS, Rettew JB, McGlashan TH: Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: findings from the collaborative longitudinal personality disorders study. J Nerv Ment Dis 2002;190:510-518.
19.
Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR: Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. Am J Psychiatry 2004;161:2108-2114.
20.
Axelrod SR, Morgan CA, Southwick SM: Symptoms of posttraumatic stress disorder and borderline personality disorder in veterans of Operation Desert Storm. Am J Psychiatry 2005;162:270-275.
21.
Morey RA, Gold AL, LaBar KS, Beall SK, Brown VM, Haswell CC, Nasser JD, Wagner HR, McCarthy G: Amygdala volume changes in posttraumatic stress disorder in a large case-controlled veterans group. Arch Gen Psychiatry 2012;69:1169-1178.
22.
Niedtfeld I, Schulze L, Krause-Utz A, Demirakca T, Bohus M, Schmahl C: Voxel-based morphometry in women with borderline personality disorder with and without comorbid posttraumatic stress disorder. PLoS One 2013;8:e65824.
23.
Ruocco AC, Amirthavasagam S, Zakzanis KK: Amygdala and hippocampal volume reductions as candidate endophenotypes for borderline personality disorder: a meta-analysis of magnetic resonance imaging studies. Psychiatry Res 2012;201:245-252.
24.
Schmahl C, Berne K, Krause A, Kleindienst N, Valerius G, Vermetten E, Bohus M: Hippocampus and amygdala volumes in patients with borderline personality disorder with or without posttraumatic stress disorder. J Psychiatry Neurosci 2009;34:289-295.
25.
Diener SJ, Wessa M, Ridder S, Lang S, Diers M, Steil R, Flor H: Enhanced stress analgesia to a cognitively demanding task in patients with posttraumatic stress disoder. J Affect Disord 2012;136:1247-1251.
26.
Pavony MT, Lenzenweger MF: Somatosensory processing and borderline personality disorder: pain perception and a signal detection analysis of proprioception and exteroceptive sensitivity. Personal Disord 2014;5:164-171.
27.
Schmahl C, Meinzer M, Zeuch A, Fichter M, Cebulla M, Kleindienst N, Ludäscher P, Steil R, Bohus M: Pain sensitivity is reduced in borderline personality disorder, but not in posttraumatic stress disorder and bulimia nervosa. World J Biol Psychiatry 2010;11:364-371.
28.
Ludäscher P, Valerius G, Stiglmayr C, Mauchnik J, Lanius RA, Bohus M, Schmahl C: Pain sensitivity and neural processing during dissociative states in patients with borderline personality disorder with and without comorbid posttraumatic stress disorder: a pilot study. J Psychiatry Neurosci 2010;35:177-184.
29.
Korzekwa MI, Dell PF, Links PS, Thabane L, Fougere P: Dissociation in borderline personality disorder: a detailed look. J Trauma Dissociation 2009;10:346-367.
30.
Stein DJ, Koenen KC, Friedman MJ, Hill E, McLaughlin KA, Petukhova M, Ruscio AM, Shahly V, Spiegel D, Borges G, Bunting B, Caldas-de-Almeida JM, de Girolamo G, Demyttenaere K, Florescu S, Maria Haro J, Karam EG, Kovess-Masfety V, Lee S, Matschinger H, Mladenova M, Posada-Villa J, Tachimori H, Viana MC, Kessler RC: Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys. Biol Psychiatry 2013;73:302-312.
31.
Wolf EJ, Lunney CA, Miller MW, Resick PA, Friedman MJ, Schnurr PP: The dissociative subtype of PTSD: a replication and extension. Depress Anxiety 2012;29:679-688.
32.
Ball JS, Links PS: Borderline personality disorder and childhood trauma: evidence for a causal relationship. Curr Psychiatry Rep 2009;11:63-68.
33.
Van Voorhees EE, Dedert EA, Calhoun PS, Brancu M, Runnals J, Beckham JC: Childhood trauma exposure in Iraq and Afghanistan war era veterans: implications for post-traumatic stress disorder symptoms and adult functional support. Child Abuse Neglect 2012;36:423-432.
34.
Hengartner MP, Ajdacic-Gross V, Rodgers S, Müller M, Rössler W: Childhood adversity in association with personality disorder dimensions: new findings in an old debate. Eur Psychiatry 2013;28:476-482.
35.
Zhang T, Chow A, Wang L, Dai Y, Xiao Z: Role of childhood traumatic experience in personality disorders in China. Compr Psychiatry 2012;53:829-836.
36.
de-Almeida CP, Wenzel A, de-Carvalho CS, Powell VB, Araújo-Neto C, Quarantini LC, de-Oliveira IR: Amygdalar volume in borderline personality disorder with and without comorbid post-traumatic stress disorder: a meta-analysis. CNS Spectr 2012;17:70-75.
37.
Bruehl H, Preibler S, Heuser I, Heekeren HR, Roepke S, Dziobek I: Increased prefrontal cortical thickness is associated with enhanced abilities to regulate emotions in free women with borderline personality disorder. PLoS One 2013;8:e65584.
38.
Rodrigues E, Wenzel A, Ribeiro MP, Quarantini LC, Miranda-Scippa A, de Sena EP, de Oliveira IR: Hippocampal volume in borderline personality disorder with and without comorbid posttraumatic stress disorder: a meta-analysis. Eur Psychiatry 2011;26:452-456.
39.
Kraus A, Esposito F, Seifritz E, Di Salle F, Ruf M, Valerius G, Ludaescher P, Bohus M, Schmahl C: Amygdala deactivation as a neural correlate of pain processing in patients with borderline personality disorder and co-occurrent posttraumatic stress disorder. Biol Psychiatry 2009;65:819-822.
40.
Driessen M, Beblo T, Mertens M, Piefke M, Rullkoetter N, Silva-Saavedra A, Reddemann L, Rau H, Markowitsch HJ, Wulff H, Lange W, Woermann FG: Posttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder. Biol Psychiatry 2004;55:603-611.
41.
Dixon-Gordon KL, Gratz KL, Tull MT: Multimodal assessment of emotional reactivity in borderline personality pathology: the moderating role of posttraumatic stress disorder symptoms. Compr Psychiatry 2013;54:639-648.
42.
Jogems-Kosterman BJ, de Knijff DW, Kusters R, van Hoof JJ: Basal cortisol and DHEA levels in women with borderline personality disorder. J Psychiatr Res 2007;41:1019-1026.
43.
Lange W, Wulff H, Berea C, Beblo T, Saavedra AS, Mensebach C, Driessen M: Dexamethasone suppression test in borderline personality disorder: effects of posttraumatic stress disorder. Psychoneuroendocrinology 2005;30:919-923.
44.
Wingenfeld K, Hill A, Adam B, Driessen M: Dexamethasone suppression test in borderline personality disorder: impact of PTSD symptoms. Psychiatry Clin Neurosci 2007;61:681-683.
45.
Wingenfeld K, Lange W, Wulff H, Berea C, Beblo T, Saavedra AS, Mensebach C, Driessen M: Stability of the dexamethasone suppression test in borderline personality disorder with and without comorbid PTSD: a one-year follow-up study. J Clin Psychol 2007;63:843-850.
46.
Daskalakis NP, Lehrner A, Yehuda R: Endocrine aspects of post-traumatic stress disorder and implications for diagnosis and treatment. Endocrinol Metab Clin North Am 2013;42:503-513.
47.
Haaland VØ, Esperaas L, Landrø NI: Selective deficit in executive functioning among patients with borderline personality disorder. Psychol Med 2009;39:1733-1743.
48.
Wingenfeld K, Mensebach C, Rullkoetter N, Schlosser N, Schaffrath C, Woermann FG, Driessen M, Beblo T: Attentional bias to personally relevant words in borderline personality disorder is strongly related to comorbid posttraumatic stress disorder. J Pers Disord 2009;23:141-155.
49.
Preissler S, Dziobek I, Ritter K, Heekeren HR, Roepke S: Social cognition in borderline personality disorder: evidence for disturbed recognition of the emotions, thoughts, and intentions of others. Front Behav Neurosci 2010;4:182.
50.
Roepke S, Vater A, Preissler S, Heekeren HR, Dziobek I: Social cognition in borderline personality disorder. Front Neurosci 2013;6:195.
51.
Marshall-Berenz EC, Morrison JA, Schumacher JA, Coffey SF: Affect intensity and lability: the role of posttraumatic stress disorder symptoms in borderline personality disorder. Depress Anxiety 2011;28:393-399.
52.
Limberg A, Barnow S, Freyberger HJ, Hamm AO: Emotional vulnerability in borderline personality disorder is cue specific and modulated by traumatization. Biol Psychiatry 2011;69:574-582.
53.
Rüsch N, Schulz D, Valerius G, Steil R, Bohus M, Schmahl C: Disgust and implicit self-concept in women with borderline personality disorder and posttraumatic stress disorder. Eur Arch Psychiatry Clin Neurosci 2011;261:369-376.
54.
Harned MS, Rizvi SL, Linehan MM: Impact of co-occurring posttraumatic stress disorder on suicidal women with borderline personality disorder. Am J Psychiatry 2010;167:1210-1217.
55.
Nepon J, Pagura J, Sareen J: Study limitations in report of suicidal behavior among women with co-occurring PTSD and borderline personality disorder. Am J Psychiatry 2011;168:328-329.
56.
Wedig MM, Silverman MH, Frankenburg FR, Reich DB, Fitzmaurice G, Zanarini MC: Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up. Psychol Med 2012;22:1-10.
57.
Zlotnick C, Johnson DM, Yen S, Battle CL, Sanislow CA, Skodol AE, Grilo CM, McGlashan TH, Gunderson JG, Bender DS, Zanarini MC, Shea MT: Clinical features and impairment in women with Borderline Personality Disorder (BPD) with Posttraumatic Stress Disorder, BPD without PTSD, and other personality disorders with PTSD. J Nerv Ment Dis 2003;191:706-713.
58.
Heffernan K, Cloitre M: 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. J Nerv Ment Dis 2000;188:589-595.
59.
Zlotnick C, Franklin CL, Zimmerman M: Is comorbidity of posttraumatic stress disorder and borderline personality disorder related to greater pathology and impairment? Am J Psychiatry 2002;159:1940-1943.
60.
Bolton EE, Mueser KT, Rosenberg SD: Symptom correlates of posttraumatic stress disorder in clients with borderline personality disorder. Compr Psychiatry 2006;47:357-361.
61.
World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, World Health Organization, 1992.
62.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington, American Psychiatric Association, 2000.
63.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Washington, American Psychiatric Association, 2013.
64.
Driessen M, Beblo T, Reddemann L, Rau H, Lange W, Silva A, Berea RC, Wulff H, Ratzka S: Is the borderline personality disorder a complex post-traumatic stress disorder? The state of research (in German). Nervenarzt 2002;73:820-829.
65.
Lewis KL, Grenyer BF: Borderline personality or complex posttraumatic stress disorder? An update on the controversy. Harv Rev Psychiatry 2009;17:322-328.
66.
Sabo AN: Etiological significance of associations between childhood trauma and borderline personality disorder: conceptual and clinical implications. J Pers Disord 1997;11:50-70.
67.
Cloitre M, Garvert DW, Brewin CR, Bryant RA, Maercker A: Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis. Eur J Psychotraumatol 2013;15:4.
68.
McLean LM, Gallop R: Implications of childhood sexual abuse for adult borderline personality disorder and complex posttraumatic stress disorder. Am J Psychiatry 2003;160:369-371.
69.
Resick PA, Bovin MJ, Calloway AL, Dick AM, King MW, Mitchell KS, Suvak M, Wells S, Witltsey S, Wolf EJ: A critical evaluation of the complex PTSD literature: implications for DSM-5. J Trauma Stress 2012;25:241-251.
70.
Sar V: Developmental trauma, complex PTSD, and the current proposal of DSM-5. Eur J Psychotraumatol 2011;2, DOI: 10.3402/ejpt.v2i0.5622.
71.
Foa E, Hembree E, Rothbaum B: Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. New York, Oxford University Press, 2007.
72.
Cloitre M, Koenen KC: The impact of borderline personality disorder on process group outcome among women with posttraumatic stress disorder related to childhood abuse. Int J Group Psychother 2001;51:379-398.
73.
McDonagh A, Friedman A, McHugo G, Ford J, Sengupta A, Mueser K, Demment C, Fournier D, Schnurr P, Descamps M: Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. J Consult Clin Psychol 2005;73:515-524.
74.
van Minnen A, Harned MS, Zoellner L, Mills K: Examining potential contraindications for prolonged exposure therapy for PTSD. Eur J Psychotraumatol 2012;3.
75.
Clarke SB, Rizvi SL, Resick PA: Borderline personality characteristics and treatment outcome in cognitive-behavioral treatments for PTSD in female rape victims. Behav Ther 2008;39:72-78.
76.
Bohus M, Dyer AS, Priebe K, Krüger A, Kleindienst N, Schmahl C, Niedtfeld I, Steil R: Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial. Psychother Psychosom 2013;82:221-233.
77.
Linehan M: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford Press, 1993.
78.
Harned MS, Korslund KE, Foa EB, Linehan MM: Treating PTSD in suicidal and self-injuring women with borderline personality disorder: development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol. Behav Res Ther 2012;50:381-386.
79.
Harned MS, Tkachuck MA, Youngberg KA: Treatment preference among suicidal and self-injuring women with borderline personality disorder and PTSD. J Clin Psychol 2013;69:749-761.
80.
Sachsse U, Vogel C, Leichsenring F: Results of psychodynamically oriented trauma-focused inpatient treatment for women with complex posttraumatic stress disorder and borderline personality disorder (BPD). Bull Menninger Clin 2006;70:125-144.
81.
Pabst A, Schauer M, Bernhardt K, Ruf M, Goder R, Rosentraeger R, Elbert T, Aldenhoff J, Seeck-Hirschner M: Treatment of patients with borderline personality disorder and comorbid posttraumatic stress disorder using narrative exposure therapy: a feasibility study. Psychother Psychosom 2012;81:61-63.
82.
Johnson DM, Shea MT, Yen S, Battle CL, Zlotnick C, Sanislow CA, Grilo CM, Skodol AE, Bender DS, McGlashan TH, Gunderson JG, Zanarini MC: Gender differences in borderline personality disorder: findings from the Collaborative Longitudinal Personality Disorders Study. Compr Psychiatry 2003;44:284-292.
83.
Kellner M: Aripiprazole in a therapy-resistant patient with borderline personality and post-traumatic stress disorder. Pharmacopsychiatry 2007;40:41.
84.
Ziegenhorn AA, Roepke S, Schommer NC, Merkl A, Danker-Hopfe H, Perschel FH, Heuser I, Anghelescu IG, Lammers CH: Clonidine improves hyperarousal in borderline personality disorder with or without comorbid posttraumatic stress disorder: a randomized, double-blind, placebo-controlled trial. J Clin Psychopharmacology 2009;29:170-173.
85.
Wingenfeld K, Driessen M, Terfehr K, Schlosser N, Carvalho SC, Otte C, Beblo T, Spitzer C, Löwe B, Wolf OT: Effects of cortisol on memory in women with borderline personality disorder: role of co-morbid post-traumatic stress disorder and major depression. Psychol Med 2013;43:495-505.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.