Episode 215: Understanding Complex PTSD and Borderline Personality Disorder

Jun 14

Adam Borecky, M.D. and David Puder, M.D.

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.

Introduction

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.

Some questions we address in this podcast to equip the next generation of mental health professions are:

What are the risk factors that may predict why trauma exposure can lead to varying clinical presentations?
What is the difference between C-PTSD and Borderline Personality Disorder (BPD)?
What are the unique struggles our patients with C-PTSD are dealing with and how can we be prepared to assist them?

To answer these questions, we will look at three pivotal studies on C-PTSD and tie it to real-world examples. Finally, we will look at some common barriers patients with C-PTSD have in seeking and engaging with mental health care.

Complex PTSD And Borderline Personality Disorder: Similarities And Differences

Complex post-traumatic stress disorder (C-PTSD) is a mental health condition that arises from prolonged or repeated trauma, especially in situations where the individual feels trapped and unable to escape. This is distinct from traditional PTSD, which typically results from a single traumatic event. Complex PTSD can be caused by various types of long-term trauma, including:

Long-term childhood psychological, physical, or sexual abuse or neglect
Prolonged domestic violence
Surviving war, torture, or kidnapping
Imprisonment or being held in captivity
Repeatedly witnessing violence or abuse
Being forced into prostitution, slavery, or other forms of exploitation

While C-PTSD shares some symptoms with PTSD, such as re-experiencing the traumatic event, avoidance of reminders, and hyperarousal, it also includes additional symptoms related to emotional regulation, self-concept, and relationship difficulties. These characteristics often overlap with borderline personality disorder (BPD), which can complicate diagnosis and treatment. BPD is characterized by frantic efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, self-harm, mood changes, chronic feelings of emptiness, temper outbursts, dissociation, and paranoia.

Complex post-traumatic stress disorder and borderline personality disorder both show increased prevalence with multiple traumas, as highlighted in the adverse childhood experiences (ACE) studies (see episode 204). Understanding C-PTSD is crucial because it addresses the profound and lasting impact of repeated trauma, which is often overlooked in clinical settings. Individuals with C-PTSD may exhibit hesitancy in forming therapeutic relationships, which can hinder effective treatment.

One significant aspect of C-PTSD is its link to avoidant (equivalent to dismissing) attachment styles. One study using a four-item questionnaire to measure adult attachment styles indicates a bivariate correlation value of 0.198 (p= .001) for dismissive attachment styles (low trust, high self-reliance) in individuals with C-PTSD (Karatzias, 2022). This avoidance in attachment reflects a deeper struggle with trust and intimacy, often rooted in early traumatic experiences. In this study they also found a correlation between disorders of self organization (found in c-ptsd) with the childhood trauma questionnaire (0.249), fearful attachment style (.288) but not preoccupied attachment style (.098, p >0.05). We would still desire for a larger study using the adult attachment interview with patients with C-PTSD to look at a more detailed analysis of attachment styles.

When patients with borderline personality disorder are tested using the adult attachment interview, only a small percentage (0% to 8% in various studies) have a secure attachment; the majority having an insecure attachment, either preoccupied (equivalent of ambivalent, a hyperactivating strategy) or unresolved (around conversations of abuse or loss, they have disorganized or disoriented reasoning or discourse). In one study by Fonagy, 32 out of 36 patients with BPD (89%) were unresolved and 75% were preoccupied (Agrawal, et al 2004). The AAI label of unresolved is in respect to a trauma or loss,

Someone with C-PTSD may experience persistent and pervasive difficulties in regulating emotions, maintaining relationships, and feeling safe in the world. These symptoms often manifest in various psychological defenses designed to protect the individual from the overwhelming pain of their trauma.

Individuals with C-PTSD may use several psychological defenses, such as:

Denial: Refusing to acknowledge the impact or reality of traumatic experiences.
Dissociation: Mentally disconnecting from parts of one's life or from feelings related to trauma, as if they are not real or did not happen.
Projection: Attributing one's own uncomfortable feelings or thoughts to someone else, believing others have those feelings towards them.
Rationalization: Coming up with seemingly reasonable explanations for events or behaviors driven by trauma.
Minimization: Downplaying the significance or effects of one’s traumatic experiences.
Idealization: Excessively praising or idealizing people involved in the trauma, avoiding acknowledgment of the harm they caused.
Intellectualization: Focusing on facts and logic to avoid dealing with the emotional aspects of trauma.
Somatization: Experiencing and expressing psychological pain through physical symptoms.

People with C-PTSD may have a history of avoiding talking or seeking help for their trauma and might say things like:

“I really put off seeing a therapist for years.”
“It wasn’t that bad.”
“Others have it much worse than me.”
“I just need to get over it.”
“I don’t remember much from that time.”
“They didn’t mean to hurt me; they did the best they could.”

Importance of Correct Diagnosis

Accurate diagnosis is crucial, when it inspires empathy and compassion for individuals and helps them achieve new levels of thriving. Learning to avoid and withdraw can be an adaptive strategy in childhood. Patients who adaptively learned avoidance strategies early on will subsequently struggle with trusting providers due to extensive interpersonal trauma and may prefer to “go it alone,” making engagement in therapy particularly challenging. Psychotherapy for avoidant or inherently distrusting individuals might require creating space for their avoidance and helping them process these feelings. On the other hand, individuals with BPD are more likely to engage in treatment, but might fluctuate from idealizing to devaluing a provider, necessitating that therapists are well-equipped to handle the unique challenges posed by these patients.

Detailed Exploration Of Key Studies

The Problem of Psychiatric Diagnosis and Comorbidity

Psychiatric diagnosis often grapples with the challenge of pattern-matching self-reported symptoms into “disorders,” which may not always reflect distinct underlying “disease states.” Unlike other medical fields, psychiatry lacks the luxury of definitive pathology, radiology, blood tests, or reliable biomarkers to aid in diagnosis. This makes the field heavily reliant on organizing symptoms statistically to create valid diagnostic categories.

The Solution: Network Analysis and Factor Analysis

Two statistical approaches used to explore relationships among symptoms are network analysis and factor analysis, particularly exploratory structural equation modeling (ESEM). While both methods seek to understand the interplay of symptoms, they approach it differently:

Network Analysis: is like observing individual friends at a party, seeing who talks to whom and who influences whom. This method looks at individual questions and how they interact with each other rather than underlying factors. It maps these direct relationships, providing insights into how symptoms influence each other directly.
Exploratory structural equation modeling (ESEM): Imagine trying to understand a group of friends by identifying their unique traits and shared characteristics. It tries to answer how many groups exist. Then it looks at how individual people relate to each group.

Knefel et al., 2016 - Network Analysis

This study of 219 adult survivors of childhood abuse used questionnaires for PTSD, C-PTSD, and BPD, applying network analysis to each symptom. Key findings include:

Three clusters of symptoms developed based on the stronger relationships of individual question with each other as seen in figure 2 and the heat map in figure 3:

PTSD cluster of symptoms:

Distressing dreams (RE1), intrusive recollections (RE2), psychological distress at reminder (RE3), internal avoidance (AV1), external avoidance (AV2), hypervigilance (TH1), exaggerated startle response (TH2)

C-PTSD (disturbances in self-organization):

Emotional numbing (AD6), worthlessness (NSC2), shame (NSC3), guilt (NSC4), feelings of failure (NSC1), no positive emotions (AD7), difficulty feeling close to others (DR2), avoidance of relationships (DR3)

BPD:

Impulsiveness (BP4), self-harm (BP5), mood changes (BP6), chronic emptiness (BP7)
Temper outbursts (BP8), dissociation/paranoid ideation (BP9)

There were some symptoms that crossed over as seen on the heat map (figure 3) that were prevalent at higher amounts (table 1):

The C-PTSD group and PTSD group seemed more related to each other than to BPD (see heat map figure 3).

For example, the C-PTSD questions all also were related to PTSD’s question about exaggerated startle (TH2).

BPD grouping had strong externalizing emotionality that was not seen in PTSD or C-PTSD.
The centrality of depersonalization and derealization connecting PTSD and C-PTSD, particularly following childhood abuse.
BPD had some unique dissociation symptoms clustering differently, suggesting a distinct type of dissociation mixed with paranoid ideation.

Note in figure 2 how BP8 “temper outbursts” and BP9 “dissociation of paranoid ideation” were strongly linked. The question for dissociation of paranoid ideation was, “Have you ever had the feeling that people were talking about you or watching you when they really weren’t?”

Hyland et al., 2019 - Factor Analysis

This study aimed to examine the discriminant validity between C-PTSD and BPD symptoms in a UK population sample. Using ESEM on self-reported measures from 546 participants, it identified a three-factor model best representing the data, showing distinct but related latent structures for PTSD, DSO/C-PTSD, and BPD symptoms.

Comparative Insights:

Core Differences in BPD and C-PTSD: C-PTSD captures a subset of individuals with a trauma history who also experience disruptions in self-organization leading to avoidance, unlike the externalizing symptoms typical of BPD. In BPD, pain often leads to a push-pull yearning for connection, whereas in C-PTSD, pain leads to withdrawal and avoidance.
Factor Loading: What factor loading shows us about PTSD, disturbances of self organization (DSO) (a unique part of C-PTSD), and BPD:

Factor 1

PTSD: The factor that contained PTSD symptoms which were strongly linked to classic PTSD symptoms including upsetting dreams, flashbacks, avoidance of reminders, being on guard, and being jumpy or startled easily. It was only slightly linked (lambda: 0.23-0.24) to the other 2 factors (DSO or BPD).

Factor 2

DSO (which we will call C-PTSD): Mostly contained links to DSO symptoms (disturbances of self-organization) which is unique to C-PTSD including emotional numbing, feeling like a failure, feeling worthless, feeling cut off from others, feeling difficulty staying close to others. Factor 2 DSO has a smaller link to questions in the PTSD factor, despite in the ICD-11 they are a requirement for the diagnosis. Table 3 shows avoidance of internal and external reminders had a lambda of .35 to .31 respectively.
Include difficulty feeling close to others, avoidance of relationships, and deactivation (inability to experience positive emotions).

Factor 3

BPD: Had high connection with individual questions that usually relate to BPD including being frantic someone close will leave, relationship ups and downs, sudden change in self-image, identity issues, impulsivity, self harm, loss of control in anger, and violence when angry.

Similarities:

Emotional Dysregulation: Both BPD and C-PTSD involve difficulties in managing emotions. Individuals with either condition may experience intense emotional responses and have trouble calming themselves down.
Interpersonal Relationship Issues: Both disorders can lead to troubled relationships. People with BPD and C-PTSD may struggle with trust and maintaining stable relationships.
Trauma-Related Origins: Both conditions can stem from traumatic experiences, particularly those involving abuse or neglect during childhood.
Dissociation: Both BPD and C-PTSD can involve dissociative symptoms, such as feeling detached from oneself or one’s surroundings.

Differences:

Sense-of-Self:

BPD: Characterized by an unstable sense-of-self, with frequent changes in self-image and identity. Individuals may experience rapid shifts in their interests, values, and goals.
C-PTSD: Individuals tend to have a more stable but consistently negative self-view, often feeling worthless, guilty, or ashamed.

Emotional Regulation:

BPD: Emotional dysregulation in BPD often involves intense, uncontrolled anger and impulsive behaviors, including self-harm and suicidal gestures.
C-PTSD: Emotional dysregulation in C-PTSD typically involves emotional numbing, withdrawal, and difficulty self-soothing. Individuals may use dissociation or substance abuse as coping mechanisms.

Interpersonal Relationships:

BPD: Individuals with BPD may have intense and unstable relationships, characterized by alternating between idealization and devaluation of others. They often fear abandonment and may go to great lengths to avoid it.
C-PTSD: People with C-PTSD often avoid close relationships altogether due to a pervasive mistrust of others, stemming from their traumatic experiences.

Core Symptoms:

BPD: Key symptoms include frantic efforts to avoid abandonment, unstable relationships, impulsivity, chronic feelings of emptiness, and recurrent suicidal behavior.
C-PTSD: In addition to PTSD symptoms (intrusive thoughts, avoidance behaviors, and increased arousal), C-PTSD includes persistent feelings of worthlessness, emotional dysregulation, and difficulties in maintaining relationships.

Diagnostic Criteria:

BPD: Diagnosed based on criteria in the DSM-5, which does not require a traumatic event for diagnosis.
C-PTSD: Recognized in the ICD-11 but not in the DSM-5. It requires a history of prolonged trauma and includes additional symptoms beyond those of PTSD.

Unified Classification Proposal

Giorou et al., 2018, argue for classifying all three disorders (PTSD, C-PTSD, BPD) under trauma-related disorders due to their common history of trauma. They suggest these diagnoses serve as markers of clinical and biological severity on a spectrum, with C-PTSD as an intermediate. This approach would treat these disorders similarly to how different types of depression are treated under an overarching diagnosis (MDD) with different subtypes (atypical, melancholic, etc.). Such a classification might better reflect the biological and clinical complexity of individuals’ diverse experiences resulting from trauma.

Key Findings

Symptom Clusters: The study identified three distinct clusters of symptoms corresponding to PTSD, C-PTSD, and BPD. Each cluster had unique and overlapping features, particularly in areas of emotional regulation, self-concept, and interpersonal relationships.
Central Symptoms: Symptoms such as emotional dysregulation, negative self-concept, and interpersonal difficulties were central in the network, indicating their pivotal role in the disorders.
Trauma Types and Symptom Severity: The type, duration, and interpersonal nature of trauma were found to significantly influence symptom severity and disorder type. Prolonged and interpersonal traumas were particularly associated with C-PTSD and BPD.

Biological Correlates

The study highlighted the following biological findings:

Neuroimaging Studies: Structural brain abnormalities, such as reduced hippocampal and amygdala volumes, were observed in both BPD and C-PTSD, indicating common neural bases for emotional dysregulation.
HPA Axis Dysfunction: Chronic stress and trauma exposure were linked to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, contributing to the development of both BPD and C-PTSD.

Unified Classification Proposal

Giourou et al. (2018) propose a unified classification system for trauma-related disorders, suggesting that PTSD, C-PTSD, and BPD should be considered part of a spectrum of trauma-related disorders. This classification is based on shared etiological factors and overlapping symptoms, emphasizing a continuum of clinical and biological severity. The authors argue that:

Trauma Continuum: PTSD, C-PTSD, and BPD exist on a continuum, with C-PTSD as an intermediate state between PTSD and more severe personality changes seen in BPD.
Biological and Clinical Overlap: The significant overlap in symptoms and biological findings supports a reclassification that reflects the interconnected nature of these disorders.

Our Reflections on Giourou et al., 2018

As those practicing in the field, we see severity as not related to diagnosis but would rather characterize severity by the following:

Avoidance of doing effective treatment
Harm to self that would stop treatment from progressing
Interpersonal factors that would either lead to avoidance of healing relationships or pushing away of healing relationships
The level of reflective function being lower
The degree of destabilization that might occur when doing treatment
The degree of comorbid other issues like drug addiction

When measuring level of functioning, one commonly used measurement is the OQ-45.2.

Summary And The future Of C-PTSD Treatment:

With this knowledge, we can now see how clusters of symptoms relate and how individuals with trauma might fit into a diagnosis of PTSD, C-PTSD and BPD but also have symptoms that are shared between categories. Having a working diagnosis might help a patient not get pulled into long-term ineffectual treatments. People with strong avoidance for effectual treatments because of their focus on the trauma, may lead them to focus on distracting or mind-numbing treatments that don’t get to the core issues in a way that would lead to long-term resolution of symptoms. The hope would be to identify core clusters of symptoms and find approaches to address those. For example, treatment strategies could prioritize central symptoms like dissociation and affect dysregulation to achieve significant clinical improvements.

Also, importantly, we desire to have empathy for the unique strategies that children develop in order to survive their traumas. Instead of taking anger that a patient with BPD may express towards you as a personal slight, we can see that externalizing behaviors might have been an adaptive strategy in the midst of trauma. Instead of seeing avoidance in a patient with C-PTSD as just not needing treatment or not liking you as the provider, you could potentially see it with the understanding that they have adaptively moved away from relationships as a way of survival. Trust for this group will be gained over a long treatment course and with a provider being consistent, warm, kind and empathic towards the difficulty of trusting.

With those things in mind, hopefully this episode increased your internal reflectiveness towards what may be really going on underneath the surface with both yourself and your clients. I imagine we don’t just need a new modality to treat C-PTSD or BPD, but rather a journey towards increasing our own reflective function.

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://www.ncbi.nlm.nih.gov/pmc/articles/PMC1857277/

Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C., Zanarini, M. 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

Battle, D. E. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM). Codas, 25(2), 191-192. https://doi.org/10.1176/appi.books.9780890425596.744053

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). 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). https://doi.org/10.3402/ejpt.v5.25097

Cloitre, M., Petkova, E., Wang, J., Lu Lassell, F. (2012). An examination of the influence of a sequential treatment on the course and impact of dissociation among women with PTSD related to childhood abuse. Depression and Anxiety, 29(8), 709-717. https://doi.org/10.1002/da.21920

Cloitre, M., Stolbach, B. C., Herman, J. L., van der Kolk, B., Pynoos, R., Wang, J., Petkova, E. (2009). A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399-408. https://doi.org/10.1002/jts.20444

Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, S, 86-100. https://doi.org/10.1037/1942-9681.S.1.86

Driessen, M., Herrmann, J., Stahl, K., Zwaan, M., Meier, S., Hill, A., Osterheider, M., Petersen, D. (2000). Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Archives of General Psychiatry, 57(12), 1115-1122. https://doi.org/10.1001/archpsyc.57.12.1115

Ehlers, A., Maercker, A., Boos, A. (2000). Posttraumatic stress disorder following political imprisonment: the role of mental defeat, alienation, and perceived permanent change. Journal of Abnormal Psychology, 109(1), 45-55. https://doi.org/10.1037/0021-843X.109.1.45

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

Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., Smith, S. M., Dawson, D. A., Pulay, A. J., Pickering, R. P., Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69(4), 533-545. https://doi.org/10.4088/JCP.v69n0404

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

Irle, E., Lange, C., Sachsse, U. (2005). Reduced size and abnormal asymmetry of parietal cortex in women with borderline personality disorder. Biological Psychiatry, 57(2), 173-182. https://doi.org/10.1016/j.biopsych.2004.10.004

Karatzias, T., Shevlin, M., Fyvie, C., Hyland, P., Efthymiadou, E., Wilson, D., Roberts, N., Bisson, J. I., Brewin, C. R., Cloitre, M. (2017). Evidence of distinct profiles of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (C-PTSD) based on the new ICD-11 Trauma Questionnaire (ICD-TQ). Journal of Affective Disorders, 207, 181-187. https://doi.org/10.1016/j.jad.2016.09.032

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.

Kernberg, O. F., Yeomans, F. E. (2013). Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis. Bulletin of the Menninger Clinic, 77(1), 1-22. https://doi.org/10.1521/bumc.2013.77.1.1

Kreisel, S. H., Labudda, K., Kurlandchikov, O., Beblo, T., Mertens, M., Thomas, C., Rullkötter, N., Wingenfeld, K., Mensebach, C., Woermann, F. G., Driessen, M. (2015). Volume of hippocampal substructures in borderline personality disorder. Psychiatry Research: Neuroimaging, 231(3), 218-226. https://doi.org/10.1016/j.pscychresns.2014.11.010

Kuhlmann, A., Bertsch, K., Schmidinger, I., Thomann, P. A., Herpertz, S. C. (2013). Morphometric differences in central stress-regulating structures between women with and without borderline personality disorder. Journal of Psychiatry and Neuroscience, 38(2), 129-137. https://doi.org/10.1503/jpn.120039

Lewis, K. L., Grenyer, B. F. (2009). Borderline personality or complex posttraumatic stress disorder? An update on the controversy. Harvard Review of Psychiatry, 17(5), 322-328. https://doi.org/10.3109/10673220903271848

McDonnell, M., Robjant, K., Katona, C. (2013). Complex posttraumatic stress disorder and survivors of human rights violations. Current Opinion in Psychiatry, 26(1), 1-6. https://doi.org/10.1097/YCO.0b013e32835aea9d

Mehta, D., Binder, E. B. (2012). Gene × environment vulnerability factors for PTSD: the HPA-axis. Neuropharmacology, 62(2), 654-662. https://doi.org/10.1016/j.neuropharm.2011.03.009

Palic, S., Zerach, G., Shevlin, M., Zeligman, Z., Elklit, A., Solomon, Z. (2016). Evidence of complex posttraumatic stress disorder (C-PTSD) across populations with prolonged trauma of varying interpersonal intensity and ages of exposure. Psychiatry Research, 246, 692-699. https://doi.org

David Puder