Psychiatry & Psychotherapy Podcast - Understanding Complex PTSD and Borderline Personality Disorder

Episode Date: June 14, 2024

The purpose of this episode is to provide a clear and simple guide for clinicians on the diagnosis of complex PTSD (C-PTSD) and how it differs from post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD). It is intended to complement and add to recent episodes on attachment and trauma: 213: Reflective Functioning, 203 and 204 on adverse childhood experiences.  In today's episode of the podcast, we are joined by Dr. Adam Borecky. Dr. Borecky is a psychiatrist and therapist who helped author the Connection Index and is part of Dr. Puder's core team. His practice utilizes a holistic approach towards therapy and medication management. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

All right, welcome back to the podcast. I am joined today with Dr. Adam Brecki. He is a psychiatrist who does psychotherapy, psychiatry in California. And he works with me in our practice to help take care of patients. And he is coming on to discuss with me complex PTSD, borderline personality disorder, PTSD, where they intersect, where they are different. As some of you may know, complex PTSD is not in the DSM-5, but is in the ICD-I-D-11. 11. 11. Yeah, you got it. And we will talk about that. We'll talk about what is uniquely complex PTSD. Is this a good new diagnostic term that is disqualification? That is discrete and separate from BPD and PTSD. We will discuss how these patients present, what makes them different, what makes them unique, potentially how to help them. This is a good episode in continuum

with the two episodes I've done on adverse childhood experiences and reflective function. Episode 213, reflective function, I think relates to this quite a bit. And so if this one's of help to you, and go back and listen to those. This one will stand alone. So Adam Brecky, welcome to the podcast. Oh, David, great to be here. Thank you for the invite. Why don't you start by describing a little bit about complex PTSD? So what complex PTSD is trying to do? It's trying to capture a subset of individuals that just don't quite fit the full criteria of traditional PTSD, as well as the adjustment disorders as well as the complicated bereavement as well as the the the the the the BPD the borderline personality disorder so that that's kind of broad strokes kind of where we were coming with this

yeah i think i think one of the general sort of ideas is complex PTSD is more of an avoidance like trauma has led to you wanting to avoid interpersonal relationships and a very sort of negative self-concept. Whereas borderline per seigneuris order, there's the cutting, the self-harm, there's a paranoid ideation, meaning like people are critical of me, people are looking at me critical.

There's, and with PTSD, there's more of the classic nightmares, flashbacks to a specific event. Yeah, I don't know. Would you, just kind of as we kind of paint the broad picture, what would you say the difference between the three entities are? Roughly speaking, the kind of the direction of the literature that all kind of agreed upon is that really there's three trauma, you know, trauma related entities

that we're trying to distinguish. That's the whole purpose of this podcast. We're talking about PTSD, you know, traditional, right? There's borderline personality disorder and then there's complex PTSD, right? So how do we focusing on complex PTSD? What are we talking about? Really? Really, we're talking about a, you know, trauma kind of matched with what seems to be a bit of an avoidant attachment style, because that showed up really strongly with the AISS studies that you looked at, too. And let me just say one thing there. So in the ICD-11, they require a trauma, whereas in the BPD, they don't require trauma. Right. And so- No, that's 100% sure. That's a huge distinction here. Yeah. Okay. Keep going.

So behaviorally speaking, right, if you have a patient in front of you and you're trying, and they're talking about their trauma history, you're doing a good trauma history, right? And you're trying to figure out, okay, what symptoms am I seeing? Some things that can kind of shift you a little bit towards the complex PTSD, a couple clues, right? So the kind of trauma that you're experiencing, is it long childhood, psychological, physical, sexual abuse or neglect? Is it prolonged domestic violence? Is it, you know, surviving a multi-year war, torture, kidnapping, imprisonment, captivity, right?

You know, a lot of patients, you know, have been forced into prostitution, even some kind of slavery as well. Like, these are all things that are kind of point towards the kind of trauma that predisposes one to a complex PTSD picture. Yeah. So you're looking at hundreds, if not thousands of events. Yes. in the realm of neglect, you're looking at tens of thousands. And there's a certain directionality that comes from that where you get symptoms of high, like, emotional numbing,

feeling like a failure, feeling worthless, feeling cut off from others. Well, yeah, well, there's a construct. So when the ICD 11 was really codified, this, they have this thing called the trauma questionnaire, which is a pretty validated tool that really tries to capture the different, the variety of traumatic experiences. And one construct that that questionnaire discusses is this thing called DSO or disturbances in self-organization. And that, that gets to exactly what you just said. It's, it's this, you know, internal, it's affective

dysregulation, which sounds like borderline, right? But it's more complex than that. There's hyperactivation, which is a little bit more of an externalizing thing, something that we tend to very much associate with borderline, right? There's also the deactivation, right? The dissociation, the depersonalization, the de-realization, also symptoms of borderline. But we also, in complex PTSD, we have this negative self-concept, this internalized sense of, you know, I'm, I'm not, the world is an unsafe place and I'm not going to engage with it. Yeah, I am not going to engage with it. I think a lot of the patients that I see like this,

they do not seek out intimate partners because of the pain associated with intimate partners. So they're not desiring or they may be, part of them may be desiring close relationships, but I would say they're avoiding it like the plague. They are moving away from people. They're moving away from treatment. You know, often people with borderline per sali disorder, Dr. Pro used to say this, and I agree. Shout out to her and the VA in the home, Melinda.

They love treatment and they will engage treatment. They start partial and they show up every day and they don't want to leave. Good treatment, they love it, right? And these patients, however, are different because they have that more avoidant attachment style. It's been adaptive for them to move away from people to be distrusting. And so these are the people that are not going to want to do treatment. Maybe they even come up with ideas about how treatment doesn't work or how therapy never works. So it's like they have an avoidance of doing the things that may help them.

overcome. Right. And so it, you know, interestingly, it doesn't have a link to male or female, but I tend to think of someone like this as that male patient that just does not want to engage treatment, right? I'm reminded of a, there was a patient I had when I was training at the Veterans Hospital in Lomelinda, and he was so resistant to any kind of therapy, but he had lost his wife, which is kind of his last social contact, you know, this Vietnam vet. And, and, even though he was willing to meet with me, I was trying to build rapport, there was always a distance. In other words, he would never let me see his face, right?

So he would prefer to do over phone, and if I was trying to talk him into seeing me over the Zoom or even God forbid in person, it was always like mediated. There was always this gap. And so that's kind of one of the paradigmatic examples that I'm thinking of when I think about a complex PTSD, especially in a male patient. Yep.

Okay, so we talked about how they tend to have a more avoidant attachment style. We could talk about some of the psychological defenses which are common, like things like denial, refusing to acknowledge the impact or reality of traumatic experiences, dissociation. So dissociating away from having any emotions around related traumas.

And with that there may be a, you know, think about denial of, no, well, it happened to me, but it was a long time ago, and it didn't cause any, you know, it doesn't cause any problems, but everything in their life says that they have a lot of psychological problems, right? And you hear patients say things like this, right? They'll say, you know, in reference to, you know, like one of their parental figures or early attachment figures, like, oh, they didn't mean to hurt me. They did the best they could, right? There's almost like a diminishing or a minimization sometimes of a lot of the, you know, what you as a therapist

are very trained to hear as, you know, deeply, deep years of neglect and emotional abuse. Yeah, and there could be, we would score those comments if they were done in the adult attachment interview. It's like, why, we'd score them low, right? Because they're not representing reality in a nuanced way. They are denying that harm was done to them

or they're minimizing or they are distancing themselves from it. Another thing is they can somaticize away from it. So they may feel the trauma in their body. It's like, you know, TMJ. It's, you know, the anger is felt in their body. Like maybe they don't verbalize the anger outwardly, like someone with BPD would. Yeah.

But it's kind of like, you know, felt on a deep level, chronic pain in different areas in a somatic way. So maybe they come and they say, well, I haven't seen a therapist. I've seen them a couple, I saw one therapist a couple times and then, you know, I haven't seen anyone. And so it's like they may come in for reasons that aren't completely related to, hey, I have complex PTSD and I want help. It could be varying reasons that they're coming in.

Like my wife told me I should come in. Or, you know, I am severely depressed and I have no social contacts at this point in my life. So I think there could be a lot of different reasons that bring them in. Yeah. And not only that, but I think they're going to be missed on a lot of the really common screeners that we use. So if like if you're in a primary care office and you're given your, you know, your patients like basic psychological screeners, for trauma, one common one is like the Caps 5, right? You know, a lot of it, especially like the VA. But are they, like, do you think, are these the kinds of patients that are going to answer those questions truthfully if their default is to somewhat minimize these traumatic experiences?

Right. It's like I know a lot of people who, if you ask them, do you drink on a regular basis on some screener? they're going to say no, even though they do drink on a regular basis. It's like, I don't want that in my medical record. I don't trust them with my information. Like, why would I, why would I tell someone the truth of what's going on? I mean, some of this, it's like you may be years into treatment, and because they have such an avoidance towards vulnerability, they haven't told you much, deepness about much that's gone on in their past. Okay, there's two studies, which we want to look at today, which really illustrate well that this thing exists. And I think you, because I'm talking to a

group of mental health professionals and because we should all be skeptical of new diagnostic categories, right? This is where my brain goes. Like, I'm not going to believe it until you prove it to me first, okay? And so this was, this was me doing that to myself. The first paper is called the Association of post-traumatic stress disorder complex, post-traumatic stress disorder, and borderline personality disorder from a network analytical perspective. Okay?

This was 2016, Knafell at all in Austria. Yeah. They looked at 219 adult survivors of childhood abuse, and they used the ICD 119, trauma questionnaire that we were describing and the skid two, which is what looks at BPD. Tell me about what is network analytical perspective for someone who doesn't understand statistical modeling. No, this is great. This is great. And I think this is, I think the more we as mental health clinicians can be versed in this kind of thing, the better for us, right? Because we are

facing a almost like a default skepticism towards the very existence of our field sometimes, especially if you go, you know, depending on who you talk to, right? And so having good valid answer. So let's get into this. So quick, quick frame, there's two course studies we're going to unpack in this episode. And they basically, they use two separate research methodologies to try to get at the question of, is complex PTSD just another way of saying borderline? Is it just, is it, And this is going to be helpful to skeptical researchers as well as skeptical public. So let's talk about this first study and what they did. So what a network analysis does, right, is you give, they gave a whole hundreds of people

that have been trauma exposed, these questionnaires, right? The ones that you mentioned that are looking for specific things. Within each of those questionnaires, there are symptoms. And what they did was they used statistics to network the symptoms of all the different trauma scales together, and they looked for interrelatedness of those symptoms. So are there some symptoms that tend to coalesce in a network? Let me pause there. So this first study is looking at specific questions and the answers to those specific questions

and how they relate to other specific questions. Okay? Yes, exactly. Whereas the second study is going to say, okay, we broke this into three factors, and now we're going to look how individual questions relate to one factor. Okay?

Yes. So, but in this one, it's like individual questions and how they relate to individual questions. So I recommend that you get this actual study and you look at some of the tables and you just spend some time looking at the tables because it's beautifully done. Yeah.

But I think what I get excited about is the skepticism in our field that there are any symptoms that relate in clusters to each other at all or that like we can learn anything about any categories and how things relate to each other. So I think I get excited. And guys, I'm on Twitter. I see the anti-psychiatry people all the time. Oh, man. They say things like psychiatry doesn't exist.

It's all BS. There's no such thing as biological aspects of mental health issues. And I'm like, do y'all know how to read a paper? Because there definitely is, like, as you go up in trauma, like, as the adverse childhood experiences increase, there are brain-related changes and there are physiologic changes. The HPA access changes. So, okay, I'm like, yeah. I love the sweeping generalizations

of some like pundits, just like, oh yeah, no, no, therapy's all BS, right? No, it's all, it's all a construct, it's all social construct, the kids just need to, you know, yeah, it's. Or the other problem is I see, it can be discouraging. Is I see people who are psychologists or people who are talking about complex PTSD,

and they're saying vague things, that I'm like, they could just be talking about PTSD. They're not clearly showing how this is different than just PTSD. It's like they're hopping on this term, complex PTSD, and they're just like utilizing it, and they don't really understand it. So I think this paper really helped me understand a couple things. Okay, get into the paper, and then we'll get in the findings of it. Let's jump in.

So quick review. Network analysis, they gave people questionnaires, PTSD questionnaires, borderline questionnaires, and the ICD trauma scares. All those things are coded, right, with different colors. So here's an example of one of the things. So if you were taken, if I was given you this questionnaire, David, you would see a question about feelings of guilt, feelings of failure, distressing dreams, temper outbursts, impulsivity, self-harm.

You would then rate, you know, how much does this apply to you, right? And then all that data, these hundreds of questions are all funneled into the, you know, statistical R, whatever, you know, system and then spit out our relationships, right? So I really agree, encourage people to look at this graph because it's, it's really, really well done. And what, let's talk about findings, right? So the association within PTSD, so what that means is that the relationship of all these symptoms that have traditionally been categorized as PTSD are much more interrelated than the

symptoms with borderline or the symptoms with complex PTSD. So you're with me there. What that implies is that these entities, these three diagnostic entities, are more internally consistent than externally consistent with each other. That suggests that, there is something there. There are three things happening rather than this all just being this hodgepodge of, you know, this all being different words, different trendy words, like complex PTSD is just a trendy word for borderline, right? This is, this is, this speaks very much against that critique. Yeah. So this convinced me, because at first my my thought was like, okay, are we just relabeling borderline per size order was something that has less stigma attached. And I do not think that

that is the case. No, agreed. And what this showed specifically was the externalizing behaviors that we see with borderline, those are distinctive and those are not present with somebody with complex PTSD, right? So this is where we get the radical impulsivity, the intense, frantic efforts to avoid abandonment, you know, the unstable interpersonal relationships, right? The temper outburst. There's like a, there's like a strong externalizing emotionality that lit up for borderline that did not light up for complex PTSD or PTSD for that matter. Okay, so this is the emotion,

the distress pointed outward is what you're saying. Correct. That's what I mean, by externalizing, which that is very classic borderline per size disorder. Yes. But a couple of interesting, interesting things though so there were this whole one of the issues in our field David is the problem of comorbidity right what that means is that when you have a patient in front of you who's

telling you symptoms so if I'm depressed or I'm anxious right well what about could could those symptoms reflect several different disease states or different diagnoses so one thing at the very center of this node here you see symptoms that do overlap so there there is something to the criticism of, hey, these things are sort of similar, right? There's some of that, right? And so at the very core of this network, those beautiful green dots that are ultimately hyper-connected with everything else, you essentially see disorders, disordered affect, right? So AD9 and 86 is what I'm looking at specifically. It's a depersonalization symptoms. It's a tendency to dissociate, right? This is common, very common to PTSD.

borderline and CP at TSD. And I think that might be behind the intuition that I think you and I both had initially of like, hey, there's a little, there's something, there's some similarity here. Yeah. And if you look at just the prevalence and the sample of depersonalization, derealization, it's about, it's about 50%. So 50% of people with childhood trauma have depersonization or de-realization. Yeah, the other one was emotional numbing or kind of a deactivation. Emotional numbing was around 40% of the sample.

And so, yeah, those can be common. There were some things that were uniquely BPD in regards to dissociation. So one of the BPD dissociation questions is the dissociation of paranoid ideation. And this question, the exact question, is have you ever had the feeling that people were talking about you or watching you when they really weren't? Okay. And so that was unique to, it kind of clustered with another one, which was

temper outbursts, interestingly. And that one was uniquely BPD. So there were specific questions that were very commonly BPD. And interestingly, that didn't really relate to some of the other BPD questions either. But yeah, so go on. No, that was an interesting factor too, is like, you know, are there, I think it gets to the question of like,

if you're doing like a Zanarini or one of these like BPD questionnaires, right, are there certain symptoms in there that are actually more predictive, more valid than others? And that's what this kind of points to a little bit is yeah, like not all the symptoms we traditionally associate with BPD are necessarily created equal. And I think that does point, to give the devil as do, that does point to a limitation of our DSM system, right? It's because it takes every single symptom as purely equivalent and you just have to get up a certain threshold.

When in reality, potentially some symptoms are more predictive of our diagnoses than others. Yeah. And so, and I was looking at figure three. and what they did was they looked at the relationship between individual questions with other individual questions. And you can see in this, there is this kind of grouping of the borderline questions and then a grouping of the complex PTSD. Correct. And so the complex PTSD questions, I think it might be important just to read some of those. so deactivation like emotional numbing deactivation inability experiencing positive emotions

there was also a lot in that group of the depersonalization de-realization there was also a lot of feelings of failure feelings of worthlessness feelings of shame and feelings of guilt feeling distant or cut off from others all of those questions though were more related to themselves than they were to the classic bpd symptoms which are things like impulsivity self-harm mood changes chronic feelings of

emptiness temper outbursts and this dissociation of paranoid ideation so those were two very separate groups and then there was a third separate group which is the PTSD group which contain questions like distressing dreams, intrusive recollections, things like psychological distress at reminder, things like that. Yeah, avoidance, your classic, you know, PTSD symptoms has been categorized.

Yeah, and so I think, I think if I'm critical of the DSM-5, they've kind of lumped together complex PTSD and PTSD. So the way that ICD 11 has separated them, I think, is actually better. Agreed. I fully agree with that because it captures this disorders of self-organization concept. And what we mean by that, just a quick reminder is the affective dysregulation,

the negative self-concept, the disturbed relationships. It captures that part that is not captured by the PTSD part. Yeah. So, okay, so, yeah, any other big findings from this? study that jumped out to you. No, I love this study. I think it's clinically useful in the sense of it will equip you as a clinician to look for specific symptoms as evidence that there may be something else going on here. Because here's the thing. And what I've noticed, too, is that almost no patient comes to me. Like blank slate, never been diagnosed. Everyone has been diagnosed with

Everybody has done their own research. Everybody's coming in with some baggage. And so that can be good, that can be bad. A lot of times it's amazing that people can, you know, proactively look into diagnoses themselves. But what this will do is allow you to kind of parse between these commonly mis, you know, confused diagnostic categories and really ask some tactful questions here to try to get to, you know, actually I think that, yes, yes, you know, borderline does make sense for you. But, however, However, you have some of these other internalizing conditions that I think points to a more complex PTSD picture. And then that can then lead you to a much more targeted psychotherapeutic or even pharmacological approach. Yeah. And I think, you know, now that we have delineated good categories, I mean, you're seeing essentially three pretty good categories for people with a lot of childhood abuse. now you can start to do some research more on complex PTSD over the years and you have kind of a delineation. And so it's like once you have the ability to kind of parse it out, then you can start to do some good research on like, okay, this is the type of treatment that works. I personally don't think that we need a new treatment for complex PTSD. I think the avoidance of treatment needs to be something that providers are astute to work with and kind of like nuance to work with.

Let's, shall we jump to the second paper? Yes. This is called examining the discriminant validity of complex PTSD and borderline persi disorder symptoms result from the United Kingdom population sample. This is Highland at all. 2019. And by the way, for those of you who don't know, we have show notes that usually contain articles with links. And so you can go look at this paper yourself, psychiatrypodcast.com. So this complex PTSD study take me through how many people they looked at and some of the basics of it. I know, absolutely. So this was a UK sample. And what they,

did was they had 546 participants that had had some kind of trauma exposure, right? And so what they did was they gave them very, very similar initial structure to the first study, but what they did was they did, you know, essentially questionnaires and structured clinical interviews to these almost, you know, 546 individuals. And then they had the symptoms. But what the difference, and this is the critical difference about these two studies, is while the first study did the network analysis, they purely looked at how the symptoms themselves interrelated, this study tries, applies a form of factor analysis to figure out, you know, are there underlying simpler structures or factors that best explain the data that we're seeing, right? So it runs the model using some statistical tricks

and it says, are all of these symptoms, are they best explained by one, two, three, three, four, five, or six factors. Because if the statistics come out and said, no, there's actually like one factor going on here, that would support the criticisms we initially discussed that said, hey, like, this whole PTSD, complex PTSD, borderline personality disorder, it's all the same thing, right? And I would say, yeah, you know, but no, that's, that's, and or two, maybe, okay, there's no such thing as complex PTSD, but borderline and PTSD, those are the only two things. That would be, that would be supported by a two factor model.

But it was the three-factor model that had the best fit to the data, right? Which is confirmatory of what we were saying in the other study that, no, there's three things going on here. There's enough evidence to say three separate factors best explain these hundreds of symptoms that these individuals are reporting. Well put. Well put. And then so now, so the first part of the study shows that, yes, three factors are the best fit. it, and then it shows how the individual questions relate to one of the three factors. And so in table three, which I highly recommend, if you spend any time on this study, look at

table three first, table three will show you individual questions and how closely they relate to the factor. So the three factors were PTSD, DSO, and BPD. So DSO is what? Yeah, that's our old friend, the disorders of self-organization, right? And this really points to that unique little flavor that is indeed the complex PTSD, the internalizing factors that are associated with trauma. Yeah, so in the DSO, you can see things.

So in this new category called Complex. You can see things like a very strong link to questions like feel like a failure Feel worthless feel cut off from others Difficulty staying close to others Those questions specifically Almost only were linked to the second factor DSO so the complex PTSD Right you know those numbers are like 0.98 which is it's kind of like a correlation,

but it's different because you're correlating an individual question to a factor, okay? Whereas, you know, emotional reactivity, which is supposed to be DSO, was more linked actually to BPD at 0.46. DSO was only 0.2. PTSD was 0.17. Right.

So all of them had it a little bit, but BPD may be more, but you can think about emotional reactivity. That's an outward expression. where that's more of the BPD, whereas the inward expression is the complex PTSD. Okay. And then other things that would typically be called BPD symptoms were actually linked to the factor to complex PTSD, which was feeling empty inside.

That was linked both to BPD and complex PTSD, but right. And probably in a similar fashion, okay? Violence when angry was negatively associated with complex PTSD. So that's helpful as well. Very. And then if you look inside of the factor three, which is the borderline per size sort of factor,

most of the BPD symptoms are like 0.6 to 0.9, somewhere in that range, there was the one symptom of emotional reactivity and emotional numbing a little bit as well that was present in the BPD people. And then if you jumped to the PTSD symptoms, BPD patients often had symptoms of being on guard and jumpy and startled, which are traditionally PTSD, but not a lot of the other PTSD symptoms. Yeah. And then, if you look at the PTSD diagnosis or the PTSD factor, which factor one, outside of the PTSD symptoms of like upsetting dreams, flashbacks, avoidance of internal reminders, avoidance of external reminders, being on guard, jumping startled, there wasn't that much of a strong link

in the BPD symptoms or the disorders of self-organization symptoms, you know, the symptoms that really fell in with the complex PTSD. Yeah, anything else jump out. at you about table three. I hope that wasn't too abstract saying that. No, I think it was good. And I think it kind of gets to some of the intuition that I think of a lot of our listeners will have, that there are similarities between these things, right? And I think what I really appreciated about these both of these studies, especially on table three, because it literally gives you numbers, is that it quantifies the interrelatedness. So an example of this would be at the very bottom of table three, where you have the three factor correlations for factor one, PTSD, factor two,

disorders of self-organization or complex PTSD or factor three borderline right and what what it does is it gives you like a relatedness coefficient and the interesting thing about that is in factor three it was yes like totally correlated with itself which is exactly what you'd expect but it was more correlated with complex PTSD than it was with PTSD so there's a little bit of an intuition there of that that's validated for me of like maybe it's like a weird spectrumy kind of thing where it's like, well, maybe complex PTA is more similar to PTSD than it is to, you know, BPD similar to complex PTSD than complex PTSD is to PTSD, which I think is interesting in and of itself. I'm not sure if you feel that jives with your clinical intuition at all.

So, yeah, so you have the factor two and factor three. So factor two would be like the complex PTSD stuff. factor three would be the borderline per size order stuff the the interrelated correlation was 0.63 to each other from borderline yeah yeah between those two complex whereas with like PTSD and complex PTSD it was only 0.24 PTSD with borderline precise order was only 0.23 what that basically means is yeah, complex PTSD and BPD are more related to each other. Yes. Than they are to PTSD, which is helpful.

All three of these jump up in the more trauma that occurs. But I would say the more severe traumas, it's like complex PTSD and BPD jump up really high. So I kind of see these both and the constellation between them. as something that can make sense of people with a lot of trauma. So sometimes you'll meet someone with a lot of trauma who's just super avoidant, doesn't want to talk about it, they don't have that high, affective range, they seem maybe more subdued, more avoidant in relationships.

That's that complex PTSD picture. Whereas someone who's more volatile, emotionally reactive, sudden mood changes, anger that loses control, you know, that's more of that BPD, but there's a lot of overlap. Like you, it's, I'm not, I'm not in this category of thinking that there are two exact categories, you know? Yeah. Yeah. Yeah. Sure. No, I know. I absolutely hear you. And I think this goes again, like, I think there has been this a little bit of like a diagnostic inflation. Because if you look at like, DSM's one through five, it's like, you know, we go from like a couple diagnoses to like, like hundreds, right? So it's like, okay, there's an intuition there that I think deserves like

some thought. With this though, I think the the truest way to talk about this data is that there is enough evidence to suggest that there is, there are three separate entities happening within the data. However, they are also extremely interconnected, meaning that there is overlap that requires some really careful thought and that therapeutic alliance that would help the patient trust you enough, especially if they're a little more on the avoidance side, to disclose to you to help you secure what really might be going on. Yep. And okay, so table four was helpful for me as well. And so this was looking at, you know, what is linked to complex BTSD or BPD. And what they found was child interpersonal trauma was more linked compared to other things like adult traumas or child non-interpersonal trauma.

So I really do see borderline per seward and complex PTSD as child interpreparedness. personal trauma being kind of like what is necessary to kind of lead to that issue. No, very much so. And then this leads, this is a little bit more in the realm of like speculation because these studies did not look at that specifically. But it makes you wonder, it's like, is the type of trauma itself predictive or the fact that, you know, for PTSD, complex PTSD and borderline the childhood interpersonal trauma they're all roughly the same coefficient they're all in the 0.24 to 0.27 range and I don't know if it parsed between exactly what kind of trauma we're talking neglect physical abuse you know violence it just made me kind of wonder it's like are there more

individual factors at play here that you add interpersonal trauma to that you're more likely to have one of the manifestations that we're seeing Yeah, and I think with our comment earlier on the link between complex PTSD and avoid it an attachment style, it's like you have, you know, an early child who's gone through various things in the first year of their life that has led to an attachment style that then they have traumas that they go through and that, you know, if there's a lot of traumas, they're going to be pushed towards one of these diagnoses. categories potentially, right? No, absolutely.

Not absolutely. And, you know, there's a lot of variables that make it very complex. It's like, I think people who are critical of diagnostic categories or psychiatry in general, they like things that are very dichotomous, like broken bone, fix broken bone. okay you fixed it yeah um whereas psychiatry is just so much more difficult to nail down or screw down that's right um it's true and i i think like cultivating comfort as clinicians with that uncertainty is is is the way to do this so i i kind of see one of the reasons i you know we wanted to do this episode is to try to equip clinicians with the knowledge that they need to navigate this genuine

chaos that is that is the human being right this genuine complexity that everyone everyone has you know their own story their own you know trauma history they've been affected and how can we bring statistics in these this knowledge to bear to alleviate their suffering which is really why we're all here yeah so okay do you want to mention this uh third study kind of tell me about that absolutely so i was trying to find like counter arguments right so i i wanted to make sure that we had kind of hit this from a couple different studies so the the two studies that i we already talked about those are pretty pivotal those are like core um in this literature there was a there was a study that i wanted to include and we're going to butcher

these names but uh giro at all this is a 2008 study and what what he did was and and his this team they make the case that, yes, there's differences enough to quantify PTSD, complex PTSD, and borderline as three separate entities. However, he actually takes an interesting approach that's not, like, based on self-report statistics. He goes a little more theoretical to underlying biological substrates. Like, he looks at the HPA axis regulation. He looks at neuroimaging studies. He looks at genetics. And he says, listen, there's actually a lot of evidence that there's, on a biological level,

there are similarities in terms of sympathetic and parasympathetic, you know, disregulation. And what he suggests in response to this is he calls it the unified classification proposal. So he's like, rather than argue at length and have long podcast episodes about trying to figure out what's the difference, he says, listen, let's just like simplify our categories here. Let's just say you have a trauma syndrome, and that trauma syndrome is ranked based on different symptoms and severity, but they are all on a spectrum, almost a little bit like the DSM took away Asperger's and made it into the autism spectrum. He's making the same case with trauma and said instead of focusing on the specifics, let's,

let's lump them in and just have a spectrum of like severity. And this is the controversial part. In that severity, he ranks them as PTSD being the least severe of these three, complex PTSD being in the middle, and borderline being the most severe clinically in this formulation. So I'd love for you to kind of respond to that a little bit. Okay, so as a clinician and not a researcher, let me respond to that by saying, I think that I would rather characterize severity based off of the avoidance of doing effective treatment, the harm to self that would stop treatment from progressing,

interpersonal factors that would lead to avoidance of healing relationships, or pushing away healing relationships, the level of reflective function being lower, I think if you go back to my reflective function episode, I think the lower the reflective function, the more work that needs to probably be done, I would say the degree of destabilization that might occur while doing treatment.

There's a lot of patients that even touching on the trauma, touching on their childhood, just even mentioning their childhood, how destabilizing is it? And I think that has more to do in my mind with the severity. And then the degree of comorbid other issues like drug addiction, which would get in the way of treatment, I think, is a very helpful way of thinking about severity.

Because if someone is, you know, like they get destabilized from talking about the trauma they go out on the weekend and regress in alcohol or meth or opiates, it can be very harmful for the progression of them getting better. So I don't know. And you could see in a lot of those things that I just mentioned, avoidance is actually going to be a very, it's going to stop treatment from progressing. So I would say it's more severe than someone who might get angry, right, lash out at their professional.

but still want to be in relationship, right? They're not someone who is extremely avoidant of being in any relationship because they're distrusting of any person. That would be a more difficult person to work with. Yeah, absolutely. And I think there's, I'm not sure exactly who gets to decide the scale we're using for severity.

I mean, I think I'm remembering, like, when Dr. Tar was talking about, talking about like Freud's definition of mental health being, you know, to be able to love and to be able to work, right? I'm wondering if to, you know, to give this, again, devil's advocate argument here, if we use that metric to just in terms of adaptive functioning, how is their, you know, relationship, the quality of their object relations, right? Their ability to function in the full world. Would you accept that as a proxy for severity of illness? I would say that there's a final common pathway that I see severely mentally ill people go down,

which is they're completely disconnected from everyone and they're very isolated. So that would be the capacity of love that you mentioned. I would say that as people get more and more ill, it's harder and harder for them to work, to do meaningful work, to know what their meaningful work is, or to be able to move towards their goals, aspirations, desires, passions. So yeah, I would say those are things that we see with more severe illness. However, I know there's a lot of, I know a lot of people who have some pretty significant trauma histories who are functioning at a pretty high level who still are in a lot of pain and suffering.

even in the midst of the busyness of life, their relationships, their marriage, their children, their... So I would be hesitant. So, yeah, it's hard for me to say this person is more severe than this other person. I dislike that characterization. And sometimes what I've found in Partial Program

is, you know, you could get a bunch of patients who are competing with each other to have the most severe pathology or the most severe stories. And there's almost, yeah, it's like we somehow have to, or you could have a person who's like, well, I don't have that big of a story, so I don't even value telling people my story.

And so as a, sometimes as a psychiatrist, I'm like, no, like you're, what you've gone through is still worthy to be discussed and processed. And so I don't know. So do you hear my hesitancy on like, yeah, yeah, yeah, I get that. Saying one person's story is worse than another. So, yeah, I think that there are scales that look at level of functioning and are personally workwise, the OQ45.

I use that a lot in my practice, which is just like how satisfied are you in your interpersonal relationships? How satisfying is your sex life? How satisfying is these different things? And so that, I think, is a good session. a session change. But I think when I'm working with an individual, I really want to also cue into these are their specific goals for seeing me. And what is bringing them to pay me to try to help them? And like, somehow I need to agree with their, I need to find some common goals that we can

have together that we can work towards. Right. Yeah. Yeah, I'm in full agreement there. I think it almost like with the patient in front of me, I don't know if it matters. It's like one question I'm not thinking of is like, oh, well, you know, where are they on this like spectrum? It's like really I'm just trying to problem solve with them. I'm trying to meet them, you know, like, you know, end well in their experience. And so yeah, I think it is, it's an interesting thought to kind of have this unified classification, proposal. One other thing I wanted to bring up was also just the, like, how do you think about the

value of diagnostic labels for the patient? Is it somehow validating? Or could you, could you make an argument that it's, that it's like maybe not as helpful? Because a lot of the professionals that all I'll see will kind of make comments like, you know, that's, that's not, you know, I don't really want to put a label on it, for example. I think it goes back to like, is this going to help the person progress in treatment or not. And I think there have been some labels that lead people to not see therapy as important at all. Like I'm bipolar and therefore I just need meds the rest of my life. And that's it. Where it's like when I get into their story, it's like, uh, they have a lot of trauma. they have a lot of symptoms that seem like the bipolar rubs up over hours and then leaves within hours

that all surround interpersonal distress. You know, this is more of the borderline person eyes disorder. Right. Picture. And so sometimes it's helpful to tell them clearly this is your treatment that you need based on this diagnosis and to kind of align them with like, okay, this is the problem. now that we know what the problem is, here's the solution.

The other thing that I think happens with a lot of patients who are avoidant of going into their childhood is they will find people that co-opted a narrative that will provide them some relief and maybe some connection, but not necessarily a solution. So they may find some person

that gives them a reason for their suffering, but then it's not an actual reason. It's not the actual reason for their suffering, right? And so you... Yeah, I see it's circular. It inevitably, like, I had a patient who was told they had Lyme disease and then was put on an antiviral medication for their Lyme disease, chronic Lyme.

And it was like, okay, chronic, it's a bacteria. Antiviral medication won't work for that. But the chronic Lyme disease gave them like, okay, this is why I'm suffering. And I don't want to go, I don't want to touch my childhood stuff. Uh-uh. Not going there. Too painful. Right.

And, you know, I mean, in therapy. I'm not like digging like an archaeologist either. Like it's coming to their mind naturally. Yeah. The important things will come. And you cannot lead. Okay, so that's the other problem that people get into. Which is like, why are diagnostic categories so important?

Because if you have a general idea, this is what's going on, there's lots of trauma. It's led to complex PTSD. They're going to avoid distressing thoughts. They may try to find other reasons. that makes sense of their thoughts. There's another category of bad clinicians that will lead them to believe

that with very leading questions direct them to a specific narrative about their life, which is not true. But it can give them a sense of identity, meaning, purpose, and it can give them a connection with this person, this important authority figure, you know, which is, it becomes problematic because Oh, yeah.

Sometimes the narrative that's created is abuse that is horrific that may not have occurred. Like there was this one clinician who was, who told my client that she was sexually abused. So she told my client that she herself had been sexually abused. Okay, so self-disclosure and then was saying that the client's problems probably had to do with sexual abuse because that's what happened with these types of symptoms. And then was asking very suggestive questions

about her relationship with her father. Yeah. And eventually the patient came back to me and I caught onto it early on. I think I've told the story before. The patient had been newly married. was having pelvic pain. I lined it up historically with the insertion of the IUD.

She took out the IUD and the pelvic pain went away. Now, normally, IUDs don't cause pelvic pain. I think they're great contraceptives. But in this case, I saw the link between the time course. She got it out. And then it was like we had one session or so on like how disturbing it was for her to imagine that maybe something had happened to her. Yeah.

And how disturbing it was to work with that therapist, right? And so you could see how someone who's suggestive, who is in pain and suffering, could be led in the wrong direction. So I think diagnostic categories are helpful because they can potentially allow us to give the correct treatment, not give incorrect treatment, not lead them towards really horrible narratives about themselves that didn't exist. and to therefore, you know, slowly help them move out of the suffering and the pain that they're in. Let me throw that back at you. Like, okay, go reviewing this. How is this going to show up in your own practice as you see clients or how has it? No, certainly.

And it already has in a sense because I think I always find myself extremely, like careful because I'm I feel like I'm not like when I'm giving a diagnosis I or discussing diagnoses I have this little like I find myself doing this really like walking on eggshells pitch if it's certain diagnoses like borderline right because because I'm trying to like weigh and figure out what what kind of baggage you know might they might my client be bringing into into this discussion, right? Because there is a sense that certain diagnoses can be almost like kept as like comfort objects, right? And so maybe a really common one that a lot of our listeners will know is like, well, you know, I'm not borderline. I'm, I'm bipolar, right? That's, that's, because there's,

there's something about that that's just very like, I don't know, it has for some reason a little little less stigma than a personality disorder, right? So anyway, that's kind of like the context. So as I was going through all this literature and trying to like hash out, oh, there's, we can parse between these things. I think I feel more equipped at listening for specific symptoms that may point me into, you know, hey, it's actually more complex than what you or I were thinking or what that past therapist you had or what were that TikTok video that you saw, right?

It's a little bit more complex than that. let's parse out your symptoms and we can focus on exactly where growth needs to take place. You know, is it in the disorders, you know, your ability to like have theory of mind with people. Is it your affective dysregulation? Shifting the focus to that, I think, is where I've come away with the most from that. Yeah. And I think I was hoping I was going to be able to find a study that, looked at complex PTSD and reflective function.

And I was unable to do that. I imagine the reflective function is low in a similar way that BPD would be. I do not know that yet. And the treatment therefore will probably have an interpersonal nature to it is what I'm thinking. Well, but I do know that therapy in general works better

if you are a higher reflective function therapist. Okay. So reflective function was done on a group of therapists. So they were looking at their adult attachment interview. The therapists with the highest reflective function had better outcomes. The therapist with the lowest reflective function, the patient stayed completely the same. So through this understanding,

I think that high reflective function is a goal of good treatment. And I would say it's the same with BPD and complex PTSD. Over time, their ability to reflect on their attachment figures will increase. So how I've seen this in my practice is I've had patients who distrust all males because of maybe four or five males throughout their life doing some serious damage and harmed at them. So they've kind of lumped together all males in the same category.

Right. So as their reflectiveness increases, they can now see like, oh, you know, although I interacted with some highly psychopathic individuals who were males, who happened to be male, there were these other males that were, you know, I don't have to interpret or reinterpret all of what they had been doing as negative.

Maybe I was projecting somewhat on them from these previously poor experiences. So I've seen that before develop as a patient's reflectiveness approves or their reflectiveness towards me. So I've had one patient who believed that I was just one session away from yelling at her as she was yelled at often in her childhood.

and she would fear substantially that I would yell at her. And over time, we were able to put words to that, how hard that was for her in her childhood to be yelled at in that way, the fear that I would yell at her, and how difficult that fear was in making her show up at all to treatment. Wow. And over time she was able to conceptualize me as different. than these people that had yelled at her.

And so it's like there's a broadening of what you might call transference. There's a broadening of their reflective function as it relates to their interpersonal relationships. And then with people who've been through a lot of abuse, it's like they can slowly start to see red flags and green flags, maybe not be attracted to people who have a ton of red flags just because that's what's familiar or to avoid everyone altogether if the people have a lot of green flags,

maybe those are the types of relationships you want. No, I love that. And just to be speculative for a minute, do you kind of conceptualize reflective functioning as like kind of operating like underneath a lot of what we've already been talking about? Like an example of that maybe one might have complex PTSD,

have all the symptoms, but because for whatever reason they have a higher level of reflective functioning, their severity is going to be reduced? Like is that one way you think about it, like operating kind of underneath that? So there was one study in particular that looked at people, adults with borderline personality disorder who had been through trauma had lower, reflective functioning, then people had been through trauma and didn't end up with BPD. So it's like when you need reflective functioning the most, you don't have it.

And so it can be, and so what reflective functioning, like if someone's talking about their childhood and they're dissociated while talking about their childhood, they're probably going to have lower reflective function, right? They're numb to it. They, it's like, traumatic, it hasn't been processed. So it's like once they go through a substantial amount of therapy, they can talk about what happened in an articulate, nuanced way. It still could be very awful what happened. But now they have a cohesive narrative. Think about dissociation is you don't have a cohesive narrative. You have a jumbled narrative of sorts. So it could be very very important to have a cohesive narrative, which is what is obtained through a lot of

sometimes painful psychotherapy. And so you ideally want to go through that therapy with someone who you can sense cares about you, although that itself is complex because as we've seen with people with borderline personality disorder or complex PTSD, they can either avoid even someone who might be a healthy person, or they can push the push-pull dynamic of BPD, where they pull you close, and then they push you away, they pull you close. And it can feel very destabilizing

to have a close attachment with anyone at some point. So, yeah, there's so many factors that go into this. I don't know if that answers the question exactly. No, no, it does. Yeah, it's helpful thinking about. how these things kind of like work on each on each other too but i think my my point in the with the it seems like the therapies that increase reflective functioning will have an interpersonal component where you're talking about what's going on between you and the client

where you put towards things like transference and you understand your own you understand your own counter transference and for you to understand your own countertransference to some degree you have to understand how your own childhood interacts with the people that you come into contact with. And so this is why I think higher reflective functioning, higher reflective function therapists have better outcomes because they understand what is their own developmental story. And so even if it is a fairly traumatic developmental story, they can not have it interact as much in a negative way with someone who has their own work to do. Yeah.

Oh, love it. Yeah. So one thing I appreciate about you, Dr. Brecki, is you have done a lot of your own work. I know you've done a lot of your own therapy. Yeah, absolutely. It's a requirement, I would say, for me to hire someone. It's like they have to both. I have to feel like I actually,

was at your wedding. I know you and your wife met each other on a research project. Okay. Yeah, absolutely. We feel indebted. I do not, I did not play matchmaker. I did not tell him he should date this person. No. But you met this person on a research project that I was doing. She has really high reflective functioning. I'm like, man, I got to ask you. It's the best thing. It's the best thing that's come out of that research, I would say. It's your marriage. That's right. I'll take it. except. Yeah. Yeah. So I appreciate your warmth and you're caring and you, I think, deeply, deeply care about the people you seek to help. And so I appreciate working with you on this project. This has been an absolute privilege. I think we talked about some pretty good stuff. And I hope

it's helpful to some other people out there too. All right. We will leave it there for today.