PTSD and PD –the diagnoses of victim and perpetrator?

Warning: This article contains references to trauma and abuse

Marlon Brando in One-Eyed Jacks (1961)

There are a lot of people online talking about the stigma attached to a diagnosis of personality disorder, ‘PD’. Some warn that the effect of this diagnosis is that their trauma will go unrecognised. They warn that a person asking for help will be treated as if they are more or less to blame for their problems. They tend to make a distinction between this stigmatised ‘PD’ diagnosis and another diagnosis that seems to take into account trauma: PTSD.

It’s not surprising that PD is viewed by some as a diagnosis of blame. Online, narcissism and narcissistic personality disorder are described more or less exclusively in connection with neglectful or abusive saviour. Some influencers use the term ‘cluster B’ as a way of understanding problematic behavioural strategies in groups of people. Cluster B is a term taken from the American diagnostic manual for psychiatry (DSM-5) – referring to a group of personality disorders. The most commonly diagnosed disorder in this group is borderline personality disorder (BPD) (AKA emotionally unstable personality disorder (EUPD)). Diagnoses are mainly used in order to point towards treatment – for an individual who has asked for help. If you were looking for help with a mental health problem, why would you want to be told you belong to this ‘cluster B’? For some this feels like adding insult to injury – like a denial of the trauma they have started to come to terms with– as if they alone are to blame for their problems.

In this article I am looking at two psychiatric diagnoses that appear a lot in social media discussions: personality disorder (‘PD’) and post-traumatic stress disorder (‘PTSD’). They have been portrayed very differently and seem to have quite different symptoms. But something has changed: the ‘Complex PTSD’ concept has now emerged. And it connects these two together. Let’s look at the concepts in turn.

PTSD

PTSD has become common parlance and there is a mainstream media understanding of what this is. It’s a concept that has remained more or less unchanged for decades after morphing from unexplained symptoms in battle-field survivors (‘Shellshock’). We understand it as a disorder that emerges after a traumatic experience. Symptoms fall into three groups: re-experiencing the past (flashbacks, nightmares), heightened startle response, and avoidance of reminders. It is understood to be a kind of anxiety disorder: a kind of vulnerability. In order to be diagnosed with PTSD, there must be an identified trauma. The popular (and accurate) view of PTSD is that it reflects something quite serious having happened to the person. There is an idea that this illness reflects more the size of the event than the resilience of the person with symptoms. We might think of a train crash or being the victim of a violent crime – we accept that something unspeakable occurred. As a concept, PTSD was born into a world grateful for the service of our soldiers. No research was needed to make the trauma connections. We expect that when asking for help, a compassionate response will be non-negotiable.

BPD

Now let’s switch to looking at the apparently different concept of ‘PD’ and its most commonly diagnosed subtype: BPD. This grew up out of both psychiatry (the medical approach to the mind) and psychotherapy and psychoanalysis. Firstly, the understanding of what BPD is has changed a lot. Originally, BPD was viewed by psychiatry as being closer to madness than to trauma reaction (Marilyn Monroe was diagnosed with ‘borderline schizophrenia’). Symptoms effect behaviour (impulsive actions that have negative side effects), emotional regulation problems and inter-personal problems (difficulties maintaining positive relationships). Unlike the criteria for a PTSD diagnosis, levels of distress can be measured not just in the identified ‘patient’ but also in other people who are impacted by their behaviour or style of relating. For a diagnosis of BPD, symptoms must be evidenced by late adolescence. There is no onset point in time – the mark of an illness. So, BPD is a disorder. A history of trauma is not required as part of diagnostic criteria. In my experience the popular view of PD is that it reflects the resilience or ‘character’ of the person with symptoms rather than a history of adversity or trauma. There is little sign here, according to mainstream media, of a ‘victim’. This concept itself was originally welcomed into the world in a non-compassionate way. BPD was for a time misunderstood as untreatable, related to madness and characterised by conscious manipulation of others. Our understanding has come a long way since then, but its journey as an idea has been very different to that of PTSD.

C-PTSD

For decades these two diagnoses were thought about in different circles of mental health and treated by different clinicians. One was more interpersonal and so affected others. And the other was an illness defined by past trauma. And then came ‘complex-PTSD’. The C-PTSD concept has been around for a while. But it is now included in the International Classification of Diseases (ICD-11). So how does this connect PTSD with BPD? There are two kinds of distinction between complex PTSD and ‘simple’ PTSD. Firstly, in C-PTSD the nature of the trauma may be repeated or more relational, and secondly there are additional symptoms: problems with emotional regulation, negative self-concept (guilt shame, or loneliness) and interpersonal problems. C-PTSD overlaps with what has been known as borderline personality disorder and to some extent with all cluster B diagnoses. BPD, C-PSTD and PTSD now fit together like string of overlapping circles, with C-PTSD acting like a bridge with elements of both PTSD and PD.

These overlaps have not actually developed. They were always there. Many soldiers coming out of active service with post traumatic symptoms had interpersonal problems not emphasised in the diagnostic criteria for PTSD. So PTSD can also be relational like BPD. Large amounts of research have established links between BPD and childhood trauma and neglect. Personality disorder treatment services tend to think of their client group as survivors of various kinds of trauma. BPD is a kind of post traumatic syndrome. Instead of these concepts being so separate, a continuum looks more likely.

The overlap between symptoms of complex PTSD and borderline personality disorder

Narcissism and C-PTSD

So, we can call BPD a kind of complex PTSD. But we can’t, surely do that with narcissistic personality disorder? Narcissism has become almost synonymous with the perpetrator. In the mainstream narrative, the trauma is experienced by the partner or child or colleague of the ‘narcissist’. There are two roles: a ‘narcissist’ and a traumatised person. A perpetrator and a victim. Sometimes, we expose once loved celebrities as perpetrators and identify their victims. Much of our news feed identifies people as being in one of these two distinct roles. Never both at the same time. Why not? Don’t we like a complex character? We like it that Darth Vader is the hero’s father, as long as Luke has none of his father’s hunger for power.

Whilst the tide is changing with BPD so that it is being acknowledged as a kind of complex PTSD, Narcissism is almost never portrayed in this way. And yet, here is narcissistic personality disorder, right next to BPD in cluster B of the DSM personality disorders. And increasingly, narcissistic personality disorder is understood to be a similar kind of pathology on a continuum with bpd³, which in turn, seems to be on a continuum with C-PTSD (see my ‘neighbours of narcissism’ post for more on this). 

Before I look at the question of whether NPD can be viewed in this way, I need to say that if it can, this does not take away any responsibility the narcissistic adult has for any stressful, exploitative or abusive behaviour. In fact, being held to account for behaviour is often the only thing that will motivate them to seek help. And I am not suggesting at all that those being impacted by such behaviour should focus on past trauma in order to ‘give them a second chance’ or accommodate abuse. This can simply delay the victim looking after their own needs. We can call out (and bring to justice) perpetrator behaviour and at the same time understand NPD as a kind of complex PTSD. After all forensic psychiatry has been working with this ‘both are true’ approach for nearly a century. So, is there actually any evidence that narcissism generally is a kind of complex PTSD?

There is research demonstrating patterns of parenting in people scoring highly on narcissism^1,2,3. The main psychological treatments for NPD and narcissism are based on an understanding that a particular set of childhood experiences are behind narcissism. In my map of narcissism article I have outlined a simple modern theory of what causes narcissism. Otto Kernberg³ is the most established authority on narcissism and NPD. He describes the kinds of adverse experiences that prime a child for narcissism. But he avoids the word trauma. Why? I don’t know. Perhaps because traditionally ‘trauma’ is a field of psychology that he does not identify with. Perhaps because the childhood experiences he describes are mostly more relational. Much more research has been done into borderline personality disorder (bpd/eupd), and there is more evidence connecting this to parenting styles and trauma.

Iconic fame, narcissism and trauma

In Narcissism, Trauma and Celebrity, I have looked so far at the lives of ten people known for their legendary contributions to culture and entertainment. I have not said that any of these had NPD. I am instead thinking of narcissism as a set of strategies in line with some established theories. I have said that the drive to reach iconic fame is itself narcissistic as a strategy for living (see my article on the performance face of narcissism). Actor Marlon Brando once used an analogy to describe the role of trauma in shaping his drive to perform. He called his talent that was so celebrated a pearl. He pointed out that a pearl forms, over time, in response to the irritation of a sand grain in a shell. The sand grain, in this analogy, was his trauma. And the point he was getting to? “Who gives a damn about the pearl?”⁴. He knew that there were other consequences in his life that were less shiny. In some of these icons I have found, in addition to performance, other narcissistic strategies that might be more associated with perpetrators. Brando, Chaplin and Elvis treated many women in an exploitative way. Savile abused hundreds. Tupac was jailed. Lennon was violent and degrading. In most of these icons I have found childhood trauma.

If we pan out from the train crash, then trauma can be any unmanageable emotional overload that leaves consequences. The overload leaves in its wake a difficulty in dealing with reminders of the trauma situation. As a result of trauma, some people can’t step onto a train. But there are others who can’t step into a close relationship in which their vulnerabilities are exposed. We can’t look on and compare the trauma of one person and another and apply scores. Yes, perhaps the details of the train crash were in the news. But the privately belittling parent with a child whose mind has developed no resilience, may have had more impact. We can, of course, look on and judge behaviour.

The ever-popular victim-perpetrator split does not always fit in any neat way to the lives of people with PTSD, or PD. Narcissism is a concept we still obsessively use to clothe the perpetrators in our news stories, and in reality, this can be thought of as a kind of post traumatic syndrome. Perhaps if narcissistic perpetrators understood their behaviour in this way, they might be more motivated and able to seek help and change their behaviour.

Disclaimer: All views expressed are my own unless otherwise stated, and do not necessarily reflect the views of any institution I have been employed by. The content here is for information and should not be interpreted as advice.

References

1.     Otway, L.J. & Vignoles, V.L (2006). Narcissism and childhood recollection: A qualitative test of psychoanalytic predictions. Personality and Social Psychology Bulletin, 32, 104-116.

2.     Brummelman, E, Thomas, S., Nelemans, S.A., Orobio de Castro, B., Overbeek, G. & Bushman, B.J. (2015). Origins of narcissism in children. Proceedings of the National Academy of Sciences 112 (12) 1659-3662.

3.     Diamond, D., Yeomans, F.E., Stern, B.L. & Kernberg, O.F. (2022) Treating Pathological Narcissism with Transference Focussed Therapy. Guildford.

4.     Mann, W.J. (2019). The Contender: The Story of Marlon Brando. Harper.