Attachment, Emotional Regulation and Relationships: Exploring CPTSD and BPD

How early relational experiences may help us understand emotional and interpersonal difficulties

What happens when the relationships we depend on for safety and care are also sources of distress?

This was one of the questions that interested me while reviewing the literature for my postgraduate Traumatology dissertation. I wanted to understand more about the relationship between childhood experiences, attachment, emotional regulation and the later presentation of Complex Post-Traumatic Stress Disorder (CPTSD) and Borderline Personality Disorder (BPD).

The research I reviewed explored associations between early caregiving experiences, difficulties regulating emotions and patterns of relating to others. It also suggested that, although CPTSD and BPD can share some features, the ways difficulties present may differ.

In this fifth article in my research series, I explore these themes and consider their relevance to trauma-informed therapeutic practice.

Understanding attachment

Attachment provides a framework for thinking about how early relationships may influence our expectations of ourselves and others.

The caregiving environment can contribute to a child’s developing sense of safety, trust and emotional security. When care is inconsistent, frightening, neglectful or abusive, developing secure emotional bonds may become more difficult.

However, attachment is not a simple explanation for adult psychological difficulties. Early relationships are one part of a much wider developmental picture, and no attachment pattern determines a person’s future.

The literature considered in my dissertation explored whether insecure and disorganised attachment may be associated with later emotional regulation difficulties, including those observed in CPTSD and BPD.

What did the research suggest?

Several studies discussed in my literature review examined the relationship between attachment and emotional regulation.

Girme (2020) explored insecure attachment in childhood in relation to emotional regulation difficulties in adulthood. Lyons-Ruth (2013) considered disorganised attachment in relation to BPD symptoms in adolescence.

Gardner (2020) examined the relationship between disorganised attachment continuing into adulthood and emotional dysregulation associated with CPTSD and BPD.

Taken together, these studies contributed to a wider discussion about the possible significance of early relational experiences. They did not, however, establish that attachment alone causes either diagnosis.

This distinction matters. Research can identify associations and patterns, but individual development is complex and shaped by many influences.

Emotional regulation: why it matters

Emotional regulation refers broadly to how we experience, manage and respond to emotional states.

Difficulties with regulation may affect relationships, decision-making, responses to stress and a person’s sense of self. They can also influence how someone responds to perceived threat, rejection, conflict or emotional closeness.

My dissertation explored how emotional dysregulation may present in CPTSD and BPD, while recognising that there is overlap between the two.

The literature suggested that BPD may involve intense emotional responses, difficulties recovering from distress, fear of abandonment and instability in relationships or sense of self.

In CPTSD, difficulties may include emotional dysregulation, persistent shame or negative self-perception, avoidance, detachment and fear of closeness.

These are broad descriptions, not fixed categories. People can experience a mixture of difficulties, and neither diagnosis can be established by one symptom or relationship pattern alone.

Under-regulation, over-regulation and trauma-related distress

One of the themes in my literature review concerned different ways of regulating distress.

The review discussed BPD in terms of under-regulation of distress, PTSD in terms of over-regulation, and CPTSD as potentially involving either pattern in response to trauma-related distress.

This is a useful area for reflection, but it should not be treated as a universal distinction. Emotional responses vary considerably between individuals and across situations. Someone may become overwhelmed by emotion at one time and feel numb or disconnected at another.

For therapists, the important question is not simply whether someone experiences intense emotions or emotional detachment. It is how these experiences occur, what they mean to the individual, what circumstances trigger them and how they affect everyday life and relationships.

Relationships, closeness and fear of abandonment

The research I reviewed also explored interpersonal differences between CPTSD and BPD.

Cloitre and colleagues and Brewin and colleagues discussed differences in relationship patterns, including the possibility that CPTSD may be associated with avoidance, fear of closeness and relational detachment, while BPD may involve intense or unstable relationships and fear of abandonment.

These distinctions may help inform assessment, but they should not be used as a checklist for deciding what diagnosis a person has. People with CPTSD may fear abandonment, and people with BPD may avoid closeness. Human relationships are more complex than diagnostic categories can fully capture.

What matters is understanding the individual pattern: how someone experiences closeness, how they respond when relationships feel uncertain, what they expect from others and how these expectations may have developed.

A trauma-informed approach can explore these questions without assuming that every relationship difficulty has the same cause.

When CPTSD and BPD occur together

The literature considered in my dissertation also explored co-occurrence of CPTSD and BPD.

Jowett (2020), for example, was discussed in relation to severe relationship difficulties among people with both diagnoses. Other research examined how childhood adversity and neglect may be relevant to presentations involving CPTSD and BPD together.

This raises important questions for assessment and formulation. Where symptoms overlap, it may be necessary to consider whether one diagnosis, the other, or both best reflect the person’s presentation.

The purpose is not to force someone’s experiences into a category. It is to develop a sufficiently nuanced understanding to guide appropriate support and treatment.

Implications for therapeutic practice

For me, this research reinforces the importance of understanding emotional and relational difficulties in context.

A trauma-informed approach may involve exploring a person’s history of relationships, their current experience of safety and trust, their responses to emotional distress and the strategies they have developed to cope.

It also means recognising that coping strategies may have served a purpose at an earlier point in someone’s life, even when they are now causing difficulties. This can support a curious, compassionate approach rather than one that labels behaviour as simply problematic.

At the same time, attachment theory and trauma history should not be used to make assumptions about an individual. Formulation needs to be collaborative, attentive to the person’s own perspective and informed by appropriate assessment.

The research I reviewed raised the possibility that a deeper understanding of attachment and emotional regulation could help inform more specific approaches to treatment. It also highlighted the need for further research into these relationships.

Reflections from my Traumatology dissertation

When I submitted my literature review in January 2022, I was particularly interested in how differences in emotional regulation and relationships might contribute to understanding CPTSD and BPD.

The literature offered useful themes to explore, but it did not provide simple answers. Associations between attachment, early adversity and adult psychological difficulties need to be understood within the limitations of the research and the complexity of individual development.

For me, the value of this work lies in its contribution to thoughtful assessment and formulation: considering the person’s experiences, understanding the function and context of their difficulties, and avoiding assumptions based on diagnosis alone.

This article reflects the literature considered in my original dissertation rather than a comprehensive review of research published since 2022.

In the next article, I will look more closely at the research itself, including the methods used to study CPTSD and BPD and why the quality and limitations of evidence matter when drawing clinical conclusions.

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Lisa Harris
Psychotherapist | Clinical Supervisor | Consultant | Qualified Traumatologist
lisaharris.uk

References

Girme (2020). Research on insecure attachment and adult emotional regulation difficulties.

Gardner (2020). Research on disorganised attachment and emotional dysregulation associated with CPTSD and BPD.

Lyons-Ruth (2013). Research on disorganised attachment and BPD symptoms in adolescence.

Jowett (2020). Research discussed in relation to relationship difficulties among people with CPTSD and BPD.

Cloitre and colleagues (2013, 2014). Research discussed in relation to CPTSD, BPD and interpersonal symptom patterns.

Brewin and colleagues (2017). Research reviewing distinctions between PTSD, CPTSD and related symptom patterns. https://doi.org/10.1016/j.cpr.2017.09.001