Empowering Providers to Confidently Diagnose and Treat ADHD in Substance Use Disorder Contexts
In my experience, I’ve noticed that many non-psychiatry trained addiction providers can be hesitant when it comes to recognizing and treating ADHD in patients with substance use disorders (SUD). This reluctance often stems from concerns about stimulant medications' potential for misuse or exacerbating addiction. However, untreated ADHD can significantly impact recovery outcomes, contributing to higher relapse rates and poorer psychosocial functioning. The purpose of these guides is to equip addiction professionals with the knowledge and confidence to accurately diagnose and treat ADHD in a SUD context, using evidence-based strategies that prioritize both efficacy and safety. By understanding how to balance the risks and benefits of stimulant and non-stimulant treatments, we can help improve recovery rates and provide comprehensive care that addresses the complex needs of these patients.
Making Sense of Trauma Responses: A Practical Guide to PTSD, Complex PTSD, and Borderline Personality Disorder
Introduction
This guide was created after listening to Episode 215 of the Psychiatry & Psychotherapy Podcast with Dr. David Puder, titled “Understanding Complex PTSD and Borderline Personality Disorder.” The episode offers a nuanced exploration of the overlapping and divergent features of Complex PTSD (C-PTSD) and Borderline Personality Disorder (BPD), grounded in current research, attachment theory, and clinical insight.
As a psychiatrist regularly working with individuals impacted by developmental trauma, I found the episode to be an excellent springboard for deeper clinical reflection. This document distills and expands on the key concepts from that discussion, integrating findings from pivotal studies and offering practical clinical guidance. It is designed to help clinicians distinguish these often-confused diagnoses, understand their underlying attachment dynamics and defenses, and provide more attuned care to patients whose survival strategies may otherwise be misunderstood as resistance or manipulation.
Whether you are new to these concepts or seeking to refine your formulation skills, I hope this resource helps bring clarity, empathy, and precision to your work with patients navigating the lasting impact of complex trauma.
🧠 Understanding the Three Conditions
| Diagnosis | Core Origin | Key Symptoms | Common Defenses | Attachment Pattern |
|---|---|---|---|---|
| PTSD | Single trauma (e.g., car accident, assault) | Flashbacks, nightmares, avoidance, hypervigilance | Dissociation, avoidance | Can vary; not always insecure |
| C-PTSD | Prolonged interpersonal trauma (e.g., abuse, captivity) | PTSD symptoms plus emotional numbing, chronic shame, worthlessness, relational detachment | Denial, dissociation, minimization, intellectualization, somatization | Often avoidant or fearful |
| BPD | Often multiple traumas plus emotional invalidation in early relationships | Emotional storms, impulsivity, unstable self-image, frantic fear of abandonment, idealization/devaluation cycles | Projection, acting out, splitting, dissociation, identity diffusion | Often preoccupied or unresolved |
🔍 Why This Matters in Clinical Practice
C-PTSD often looks like BPD but is more rooted in shame, avoidance, and emotional numbing rather than impulsivity or splitting.
BPD tends to be more emotionally volatile, with a push-pull dynamic in relationships and therapy.
Accurate diagnosis allows for more targeted empathy and treatment. Misdiagnosis can lead to ineffective or even retraumatizing interventions.
🧩 Shared Features of Borderline Personality Disorder and Complex PTSD
| Domain | Shared Characteristics |
|---|---|
| Emotional Dysregulation | Both involve difficulty managing emotions. Individuals may experience intense affect and struggle to self-soothe. |
| Relationship Challenges | Both disorders can lead to unstable or distant relationships due to issues with trust, attachment, and fear of intimacy. |
| Trauma Origins | Both conditions are commonly rooted in early and repeated trauma, especially abuse or neglect during childhood. |
| Dissociative Symptoms | Individuals may experience dissociation, such as feeling detached from self or surroundings. |
🧩 Key Differences Across Clinical Domains
| Domain | Borderline Personality Disorder | Complex-PTSD |
|---|---|---|
| Sense of Self | Unstable self-image with frequent shifts in values, goals, and identity | Stable but persistently negative self-view, marked by guilt, shame, and worthlessness |
| Emotional Regulation | Intense, uncontrolled emotions; impulsive behaviors including self-harm and suicidal gestures | Emotional numbing, withdrawal, and difficulty self-soothing; may use dissociation or substances |
| Interpersonal Style | Turbulent relationships marked by alternating idealization and devaluation; intense fear of abandonment | Avoidant of close relationships due to pervasive mistrust rooted in prolonged trauma |
| Core Symptoms | Fear of abandonment, impulsivity, unstable relationships, chronic emptiness, recurrent suicidal behavior | PTSD symptoms plus emotional dysregulation, shame, interpersonal difficulties |
| Diagnostic Criteria | DSM-5 diagnosis; trauma history not required | ICD-11 diagnosis; requires prolonged trauma with symptoms beyond classic PTSD |
🧬 Research Takeaways You Can Use
This section highlights key findings from recent studies that use advanced statistical methods such as network and factor analysis to explore the connections between PTSD, C-PTSD, and BPD. The research reveals distinct but overlapping symptom clusters, shared biological features, and the influence of trauma and attachment history. These insights support a more accurate and compassionate understanding of trauma-related disorders, helping clinicians move beyond symptom checklists and toward more individualized care.
Network Analysis (Knefel et al., 2016)
Symptoms cluster into three distinct groups: PTSD, C-PTSD, and BPD.
C-PTSD overlaps most with PTSD, not BPD.
BPD has externalizing symptoms (anger, paranoia) not seen in C-PTSD.
Factor Analysis (Hyland et al., 2019)
Found three separate latent factors: PTSD, C-PTSD (Disturbances in Self Organization), and BPD.
C-PTSD and BPD are distinct syndromes even though they share trauma origins.
Clinical Tip: Think of C-PTSD and BPD as siblings from the same trauma household but with very different personalities and relational strategies.
🧬 Research in Depth: Unified Model of Trauma-Related Disorders
Giourou et al. (2018) suggest that PTSD, C-PTSD), and BPD all belong to a spectrum of trauma-related disorders. Rather than being separate conditions, they may reflect different levels of severity and different ways people respond to trauma. In this model, C-PTSD falls in the middle, between classic PTSD and the more severe relational and identity issues seen in BPD.
This idea is similar to how subtypes of depression are grouped under major depressive disorder. It allows for a more flexible understanding of how trauma shapes symptoms, relationships, and functioning.
🔑 Key Findings
| Domain | Summary |
|---|---|
| Symptom Groups | PTSD, C-PTSD, and BPD have distinct symptom patterns but also overlap, especially in emotional and relational issues. |
| Core Issues | All three involve emotional dysregulation, low self-worth, and difficulty in relationships. |
| Trauma Type | Long-lasting and relational trauma, especially in childhood, is more likely to lead to C-PTSD or BPD than to PTSD alone. |
🧠 Biological Correlates
Neuroimaging Studies: Reduced hippocampal and amygdala volumes are seen in both BPD and C-PTSD, implicating common neural pathways for affect regulation and threat detection.
HPA Axis Dysregulation: Chronic trauma contributes to lasting changes in stress response systems, particularly via disruption of the hypothalamic-pituitary-adrenal (HPA) axis, in both BPD and C-PTSD.
🧩 Clinical Implications of a Unified Model
| Concept | Implication |
|---|---|
| Trauma Continuum | PTSD, C-PTSD, and BPD reflect different degrees of trauma severity and adaptation, not different causes. |
| Overlap in Treatment Needs | Each diagnosis may benefit from trauma-informed care, affect regulation work, and attachment-focused therapy. |
| Beyond Diagnostic Labels | Understanding patients through the lens of trauma survivorship may reduce stigma and increase therapeutic alliance. |
🧰 Practical Clinical Pearls
This section offers focused guidance for working with patients who present with features of PTSD, C-PTSD, or BPD. It highlights how attachment patterns, defense mechanisms, and engagement styles can inform your clinical approach. Use these insights to build stronger therapeutic alliances, avoid common misinterpretations, and tailor treatment to each patient’s trauma history and relational needs.
1. Therapeutic Engagement
C-PTSD: Patients may seem “disinterested” or "emotionally distant," but it’s often an adaptive avoidance strategy. They need consistency, warmth, and patience.
BPD: They often engage quickly and intensely but may test boundaries. It’s essential to stay grounded and non-reactive while being empathically present.
2. Attachment Style Implications
Avoidant/Dismissing (C-PTSD): Low trust, high self-reliance. Patients might say, “I don’t need anyone,” or minimize the trauma.
Preoccupied (BPD): High emotional need, low self-worth. Patients might idealize you one week and devalue you the next.
3. Defensive Styles
Use defenses as clues to the trauma and coping history:
C-PTSD: Tends to intellectualize or dissociate try to gently bring emotions into awareness without overwhelming them.
BPD: Externalizes pain through self-harm, rage, or chaotic relationships respond with structure and empathic limit-setting.
💡 Conceptual Reframe for Empathy
This section invites you to shift your perspective on challenging behaviors often seen in C-PTSD and BPD. Instead of viewing these behaviors as resistance or manipulation, they can be understood as adaptive survival strategies shaped by trauma. Reframing in this way fosters compassion, strengthens therapeutic relationships, and supports more effective, individualized care.
💡 Conceptual Reframe for Empathy
| Behavior | Instead of assuming... | Try understanding it as... |
|---|---|---|
| “She pushes me away every time we get close.” | Resistance | A survival adaptation rooted in betrayal trauma (C-PTSD) |
| “He’s manipulating me with his threats.” | Manipulation | A desperate strategy for attachment regulation (BPD) |
| “She doesn’t care about treatment.” | Lack of motivation | Emotional numbing and mistrust learned through trauma (C-PTSD) |
| “He loves me one day and hates me the next.” | Mood swings | Fear of abandonment paired with intense need for closeness (BPD) |
Treatment Implications
For C-PTSD
Use trauma-informed, attachment-sensitive approaches.
Prioritize safety, emotional regulation, and slowly building trust.
Explore somatic symptoms as expressions of emotional pain.
May benefit from EMDR, Skills Training in Affective and Interpersonal Regulation (STAIR), and parts work (e.g., IFS).
For BPD
Structure and consistency are key.
Use DBT or mentalization-based therapy.
Help patients build a coherent sense of self and regulate emotions in relationships.
Address trauma once emotion regulation improves.
Final Thought
Diagnoses are maps, not territories. Both C-PTSD and BPD often arise from early, chronic trauma. But their strategies for survival avoidance versus emotional overdrive require different relational responses from us as clinicians.
Helping these patients means offering curiosity over judgment, and stability over solutions knowing that trust grows slowly, and healing often hides behind what looks like resistance.
📚 References
Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment studies with borderline patients: A review. Harvard Review of Psychiatry, 12(2), 94–104. https://doi.org/10.1080/10673220490447218
Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C., Sanislow, C. A., Skodol, A. E., Gunderson, J. G., Grilo, C. M., McGlashan, T. H., & Morey, L. C. (2004). Childhood maltreatment associated with adult personality disorders: Findings from the Collaborative Longitudinal Personality Disorders Study. Journal of Personality Disorders, 18(2), 193–211. https://doi.org/10.1521/pedi.18.2.193.32777
Bryant, R. A. (2010). The complexity of complex PTSD. American Journal of Psychiatry, 167(8), 879–881. https://doi.org/10.1176/appi.ajp.2010.10040606
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615–627. https://doi.org/10.1002/jts.20697
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(1), 20706. https://doi.org/10.3402/ejpt.v4i0.20706
Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5(1), 25097. https://doi.org/10.3402/ejpt.v5.25097
Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1(9). https://doi.org/10.1186/2051-6673-1-9
Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018). Complex post-traumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry, 8(1), 12–19. https://doi.org/10.5498/wjp.v8.i1.12
Hyland, P., Karatzias, T., Shevlin, M., & Cloitre, M. (2019). Examining the discriminant validity of complex posttraumatic stress disorder and borderline personality disorder symptoms: Results from a United Kingdom population sample. Journal of Traumatic Stress, 32(4), 552–561. https://doi.org/10.1002/jts.22444
Karatzias, T., Shevlin, M., Ford, J. D., Fyvie, C., Grandison, G., Hyland, P., & Cloitre, M. (2022). Childhood trauma, attachment orientation, and complex PTSD (C-PTSD) symptoms in a clinical sample: Implications for treatment. Development and Psychopathology, 34(3), 1192–1197. https://doi.org/10.1017/S0954579421001785
Knefel, M., Garvert, D. W., Cloitre, M., & Lueger-Schuster, B. (2016). The replicability of ICD-11 complex post-traumatic stress disorder symptom networks in adults. Psychological Medicine, 46(9), 1923–1934. https://doi.org/10.1017/S0033291716000345
Puder, D. (Host). (2024, April 24). Understanding Complex PTSD and Borderline Personality Disorder (Episode 215) [Audio podcast episode]. In Psychiatry & Psychotherapy Podcast. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-215-understanding-complex-ptsd-and-borderline-personality-disorder