How should a clinician proceed when a female patient diagnosed with complex post‑traumatic stress disorder (C‑PTSD) and emotionally unstable personality disorder (EUPD) wants the EUPD diagnosis removed?

Managing a Request to Remove an EUPD Diagnosis in a Patient with C-PTSD

Direct Recommendation

The clinician should conduct a comprehensive diagnostic reassessment using ICD-11 criteria to determine whether the EUPD diagnosis remains clinically valid alongside C-PTSD, and if both diagnoses are met, prioritize the C-PTSD diagnosis unless the EUPD diagnosis provides clinically useful information not captured by C-PTSD alone. 1

Understanding the Diagnostic Overlap

The request to remove the EUPD diagnosis is clinically reasonable given the substantial overlap between C-PTSD and EUPD (also known as borderline personality disorder):

• C-PTSD and EUPD share core features including emotion dysregulation, interpersonal difficulties, and negative self-perception, with childhood trauma frequently underlying both conditions 1
• ICD-11 formally recognizes this overlap and allows both diagnoses to be assigned simultaneously, but provides guidance on when this is appropriate 1
• The key distinguishing feature is that C-PTSD requires documented trauma history and core PTSD symptoms (re-experiencing, avoidance, hyperarousal), while EUPD does not 1, 2

Diagnostic Reassessment Framework

Step 1: Verify C-PTSD Diagnosis

Confirm the patient meets ICD-11 criteria for C-PTSD, which requires:

• Core PTSD symptoms: re-experiencing, avoidance, and sense of current threat 3
• Disturbances in self-organization: emotion dysregulation, negative self-concept, and interpersonal difficulties 3
• Clear trauma history: typically sustained or multiple trauma exposures such as childhood abuse 3

Step 2: Evaluate EUPD-Specific Features

Determine if EUPD features exist beyond what C-PTSD explains:

• Unstable or contradictory sense of self: C-PTSD typically involves stable, persistently negative self-perception, while EUPD may involve fluctuating between overly negative and overly positive self-views 1
• Interpersonal pattern differences: C-PTSD emphasizes avoidant interpersonal patterns, while EUPD may show more chaotic, unstable relationship patterns with intense fear of abandonment 4
• Identity disturbance quality: EUPD involves lack of coherent identity and chronic feelings of emptiness that may differ from trauma-related negative self-concept 4

Step 3: Apply ICD-11 Diagnostic Hierarchy

When both diagnoses are met, assign only C-PTSD unless EUPD provides clinically useful information not covered by C-PTSD 1. This is the critical decision point:

• If the patient's symptoms are fully explained by trauma-related disturbances in self-organization, remove the EUPD diagnosis 1
• If there are additional features (unstable identity, abandonment fears, impulsivity) that provide treatment-relevant information beyond C-PTSD, retain both diagnoses 1

Clinical Rationale for Diagnosis Removal

There are compelling reasons to favor C-PTSD as the primary diagnosis:

• Reduced stigma: EUPD/borderline personality disorder carries significant stigma that can negatively impact therapeutic relationships and patient self-perception 4
• Treatment implications: C-PTSD diagnosis directs clinicians toward trauma-focused interventions, which are evidence-based first-line treatments 5
• Diagnostic parsimony: A single diagnosis that explains the full clinical picture is preferable to multiple overlapping diagnoses 1
• Patient autonomy: The patient's perspective on their diagnosis should be respected when clinically appropriate, as this supports therapeutic alliance 6

Treatment Implications of Diagnostic Clarification

Regardless of whether EUPD is retained or removed, initiate trauma-focused psychotherapy immediately without requiring prolonged stabilization 5:

• First-line treatment: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR) should be offered without delay 5
• No stabilization phase required: Current evidence does not support delaying trauma-focused treatment for patients with complex presentations, emotion dysregulation, or dissociation 5
• Emotion dysregulation improves with trauma processing: These symptoms respond directly to trauma-focused work rather than requiring separate stabilization interventions 5

Critical Pitfalls to Avoid

• Do not delay treatment by insisting on prolonged stabilization before trauma processing, as this communicates to the patient that they are incapable of processing traumatic memories and may reduce treatment motivation 5, 7
• Avoid labeling the patient as "too complex" for standard trauma-focused treatment, as this assumption lacks empirical support and may restrict access to effective interventions 5
• Do not assume EUPD features require different treatment than C-PTSD, as both respond to trauma-focused interventions that address emotion dysregulation and interpersonal difficulties 5

Documentation and Communication

When revising the diagnosis:

• Document the clinical reasoning for removing or retaining the EUPD diagnosis, referencing ICD-11 criteria and the patient's specific symptom profile 1, 2
• Explain to the patient how C-PTSD captures their difficulties and why this diagnosis is more appropriate for guiding treatment 8
• Communicate with other providers about the diagnostic change to ensure continuity of care and appropriate treatment planning 8
• Reassess periodically: Diagnostic formulation may evolve as treatment progresses and more information becomes available 2

When to Retain Both Diagnoses

Retain both C-PTSD and EUPD diagnoses only if:

• Unstable identity features exist that fluctuate between extremes rather than showing stable negative self-perception 1
• Abandonment-driven behaviors are prominent and not fully explained by trauma-related avoidance 1
• Impulsive behaviors (self-harm, substance use, risky sexual behavior) occur outside trauma-related contexts and require specific intervention 4
• The EUPD diagnosis provides treatment-relevant information that would be lost if only C-PTSD were diagnosed 1