© Springer International Publishing Switzerland 2015
Ulrich Schnyder and Marylène Cloitre (eds.)Evidence Based Treatments for Trauma-Related Psychological Disorders10.1007/978-3-319-07109-1_1717. Treating PTSD and Borderline Personality Disorder
(1)
Department of Psychology, University of Washington, 355915, Seattle, WA 98195, USA
Borderline personality disorder (BPD) is a severe and complex psychological disorder characterized by pervasive emotion dysregulation, unstable relationships, impulsive behavior, and recurrent suicidal and non-suicidal self-injury (NSSI). PTSD is one of the most common co-occurring disorders among individuals with BPD, with comorbidity rates ranging from approximately 30 % in community samples (Grant et al. 2008; Pagura et al. 2010) to 50 % in clinical samples (Harned et al. 2010; Zanarini et al. 1998). There are several theoretical models to explain the high comorbidity between BPD and PTSD. Some models focus on the common etiological factors between the two disorders. For example, childhood abuse has been implicated in the development of both BPD and PTSD (Widom 1999; Widom et al. 2009). Other models propose that PTSD mediates the relationship between trauma exposure and BPD criterion behaviors. For example, PTSD symptoms of reexperiencing and avoidance/numbing have been found to mediate the relationship between childhood sexual abuse and NSSI (Weierich and Nock 2008). Finally, some models suggest a reciprocal relationship such that each disorder functions to maintain the other. For example, PTSD has been shown to exacerbate BPD criterion behaviors, such as emotion dysregulation, suicide attempts, and NSSI (Pagura et al. 2010; Harned et al. 2010; Marshall-Berenz et al. 2011) and to decrease the likelihood of achieving diagnostic remission from BPD over 6 and 10 years of naturalistic follow-up (Zanarini et al. 2004, 2006). Conversely, BPD is associated with high experiential avoidance (Iverson et al. 2012), which is likely to maintain PTSD (Shenk et al. 2014). Given the multiple and complex relationships between PTSD and BPD suggested by these models, successful treatment of both disorders is likely necessary to achieve optimal outcomes for individuals with this comorbidity. In this chapter, we will review research on treatment approaches for individuals with PTSD and BPD, discuss common challenges that arise during trauma-focused treatment with this population, and present a case example.
17.1 Treatment Approaches for Co-occurring PTSD and Borderline Personality Disorder
Three general approaches have been evaluated as treatments for PTSD among individuals with BPD, including (1) single-diagnosis treatments, (2) phase-based treatments, and (3) integrated treatments. Single-diagnosis treatments focus solely on treating PTSD, and any improvements in comorbid problems occur as a secondary result of targeting PTSD. Phase-based treatments include an initial treatment phase targeting comorbid problems followed by a second phase of trauma-focused treatment. Some phase-based treatments also include a third phase in which psychosocial functioning is typically addressed. Finally, integrated treatments are designed to provide comprehensive, idiographic treatment for individuals with PTSD and BPD by targeting the full range of problems with which clients may present, including but not limited to both of these disorders and the factors explaining the relationships between them. The present review will focus on treatments from each of these general approaches that have been evaluated in terms of their specific effectiveness for individuals with PTSD and BPD. While several other treatments for PTSD have included individuals with BPD (e.g., Cloitre et al. 2010; Mueser et al. 2008; Sachsse et al. 2006), they will not be reviewed here as they have not reported outcomes specific to this subgroup.
17.1.1 Single-Diagnosis Treatments
17.1.1.1 Cognitive Processing Therapy (CPT) (Chap. 10)
CPT is a brief, outpatient treatment for PTSD that is typically delivered in 12 weekly or biweekly individual sessions (Resick and Schnicke 1993). The treatment includes cognitive therapy to identify and challenge trauma-related beliefs and exposure in the form of writing and reading about the traumatic event. To date, one study has evaluated the effect of borderline personality characteristics (BPC) on outcomes in a randomized controlled trial (RCT) comparing CPT to prolonged exposure (PE) (Clarke et al. 2008). Participants included 131 female sexual assault survivors with PTSD, of whom 39 (25.2 %) were above the cutoff for a clinical level of BPC according to self-report. Women with serious suicidal intent, recent suicidal or self-injurious behavior, ongoing abuse, or current substance dependence, bipolar or psychotic disorders were excluded. Results indicated that BPC scores were unrelated to treatment dropout, and there was no evidence that BPC was related to worse outcomes in the rate of change in PTSD and other trauma-related symptoms (e.g., dissociation, depression, sexual concerns). The interaction between type of treatment (CPT or PE) and BPC score was not significant for any outcome, indicating that both treatments were comparably effective for individuals with BPC.
17.1.1.2 Prolonged Exposure (PE) (Chap. 8)
PE is a brief, outpatient treatment for PTSD that is typically delivered in 10–15 weekly or biweekly individual sessions (Foa et al. 2007). The primary PE treatment components include imaginal exposure to the trauma memory and in vivo exposure to feared but non-dangerous situations. In addition to the study of PE and CPT reviewed above (Clarke et al. 2008), a second study examined the impact of full or partial BPD on treatment outcome in an RCT comparing PE, stress inoculation training (SIT), and a combined PE/SIT treatment (Feeny et al. 2002). Treatment was delivered in 9 biweekly individual sessions. Participants were female assault survivors with a primary diagnosis of PTSD who were not acutely suicidal, had no recent history of suicidal or self-injurious behavior, were not currently involved in an abusive relationship, and did not meet criteria for substance dependence, bipolar, or psychotic disorders. Analyses were conducted using the treatment completer sample (n = 58), of whom 9 (15.5 %) met full or partial criteria for BPD. Given the small number of participants with BPD, analyses were not conducted separately by treatment type. When the three treatments were combined, BPD was not significantly related to outcome. However, women with full or partial BPD were significantly less likely than those without BPD to achieve good end-state functioning (11 % vs. 51 %), which was defined as being below clinical cutoffs for PTSD, depression, and anxiety.
17.1.1.3 Narrative Exposure Therapy (NET) (Chap. 12)
NET is a short-term treatment for PTSD that is designed for survivors of multiple and complex traumas such as victims of organized violence and conflict (Schauer et al. 2011). NET is typically delivered in 5–10 weekly or biweekly individual sessions. The primary component of NET is the creation of a written, cohesive narrative that integrates traumatic events into the individual’s larger life story. An open trial feasibility study evaluated NET among ten women with PTSD and co-occurring BPD (Pabst et al. 2012). Women actively engaging in NSSI were included, but those with acute suicidality, a recent suicide attempt, and other severe comorbidities (e.g., drug abuse, psychosis) were excluded. Treatment occurred primarily in inpatient settings, although three women were treated solely on an outpatient basis. The average duration of treatment was 14 sessions. From pretreatment to 6 months after therapy, there were large and significant improvements in PTSD, depression, and dissociation, but not BPD symptoms.
17.1.2 Phase-Based Treatments
17.1.2.1 Dialectical Behavior Therapy for PTSD (DBT-PTSD)
Bohus and colleagues (Bohus et al. 2013; Steil et al. 2011) have developed an adaptation of dialectical behavior therapy (DBT) for PTSD related to childhood sexual abuse. DBT-PTSD is delivered as a 12-week residential treatment that includes three treatment phases: (1) Weeks 1–4: psychoeducation; identification of typical cognitive, emotional, and behavioral strategies to escape emotions; and teaching of DBT skills to control these behaviors. (2) Weeks 5–10: trauma-focused cognitive and exposure-based interventions. (3) Weeks 11–12: radical acceptance of trauma-related facts and addressing psychosocial functioning. Clients receive biweekly individual sessions (23 sessions total) and several group interventions, including group skills training (11 sessions total), group focused on self-esteem (8 sessions total), and group mindfulness practice (3 sessions total). In addition, clients attend three nonspecific groups each week (e.g., music and art therapy). An RCT has evaluated the efficacy of DBT-PTSD for women with and without BPD in comparison to a treatment as usual-waitlist control (TAU-WL) (Bohus et al. 2013). Participants were 74 women with childhood sexual abuse-related PTSD, including 33 (44.6 %) who met criteria for BPD. Women actively engaging in NSSI were included, and those with a life-threatening behavior in the prior 4 months, current substance dependence, a lifetime diagnosis of schizophrenia, or a body mass index less than 16.5 were excluded. DBT-PTSD was superior to TAU-WL in improving PTSD, depression, and global functioning, but not global symptom severity, dissociation, or BPD symptoms. These results were comparable for the subgroup of women with BPD in each condition, and BPD severity was generally unrelated to treatment outcome. Among women with BPD who received DBT-PTSD, the rate of remission of PTSD was 41.2 %. There was no evidence of worsening of PTSD, NSSI, or suicidality in DBT-PTSD.
17.1.3 Integrated Treatments
17.1.3.1 Dialectical Behavior Therapy (DBT)
DBT is a comprehensive, principle-driven treatment for individuals with BPD that is rooted in behavior therapy and incorporates dialectical philosophy and elements of western contemplative and eastern Zen practices (Linehan 1993a, b). Standard DBT is typically provided as a 1-year outpatient treatment and includes 4 weekly treatment modes: individual therapy, group skills training, therapist consultation team, and telephone consultation (as needed). As an integrated treatment, DBT is designed to simultaneously treat multiple problems according to a hierarchy of treatment targets, including (1) life-threatening behaviors, (2) therapy-interfering behaviors, and (3) behaviors that interfere with quality of life. Within this target hierarchy, PTSD is considered a quality of life problem that is targeted once life-threatening and therapy-interfering behaviors are sufficiently controlled. Although the DBT manual recommends the use of exposure to treat PTSD, it does not include a protocol specifying exactly when or how to do so. Without a specific protocol for treating PTSD, 33–35 % of recently and recurrently suicidal and self-injuring women with BPD achieve remission from PTSD during 1 year of DBT and up to 1 year of follow-up (Harned et al. 2008, 2014). In addition, PTSD predicts less improvement in NSSI and suicidality during DBT (Barnicot and Priebe 2013; Harned et al. 2010).
17.1.3.2 DBT with the DBT Prolonged Exposure Protocol (DBT + DBT PE)
The DBT PE protocol was developed to improve the effects of standard DBT on PTSD, particularly for suicidal and self-injuring individuals with BPD (Harned 2013). The DBT PE protocol is based on PE, and the primary treatment components include imaginal and in vivo exposure. DBT strategies are incorporated into PE (e.g., to target problems that may occur during or as a result of trauma-focused treatment), and structured procedures are included to address complexities common in this client population (e.g., multiple, often fragmented trauma memories, intense shame, traumatic events that do not meet the standard definitions of trauma such as rejection, invalidation, and betrayal). The combined DBT and DBT PE protocol treatment lasts 1 year and begins with standard DBT focused on stabilizing life-threatening behaviors and other higher-priority targets. The DBT PE protocol is integrated into individual DBT therapy sessions if/when clients meet specified readiness criteria (e.g., not at imminent risk of suicide, no suicide attempts or NSSI for at least 2 months, no serious therapy-interfering behaviors, able and willing to experience intense emotions without escaping). Following completion of the DBT PE protocol, the rest of the treatment year uses standard DBT to address the client’s remaining treatment goals, which often include improving psychosocial functioning.
To date, DBT + DBT PE has been evaluated in an open trial (n = 13) (Harned et al. 2012) and an RCT (n = 26) that compared DBT with and without the DBT PE protocol (Harned et al. 2014). Both studies included women with BPD, PTSD, and recent (past 2–3 months) suicidal behavior or NSSI and excluded those with bipolar or psychotic disorders. Across both studies, the DBT PE protocol was feasible to implement for 80–100 % of treatment completers who started the protocol after an average of 20 weeks of DBT; of these, 73 % completed the full protocol in an average of 13 sessions. DBT + DBT PE was highly acceptable to clients and therapists in terms of treatment expectancies and satisfaction, and a majority of clients (73.8 %) reported a preference for DBT + DBT PE compared to either DBT or PE alone (Harned et al. 2013). Across both studies, DBT + DBT PE clients in the intent-to-treat samples showed large and significant improvements in PTSD severity as well as high rates of reliable improvement (70.0–83.3 %) and remission of PTSD (58.3–60.0 %). In the RCT, clients who completed the DBT PE protocol were two times more likely than those who completed DBT to achieve remission from PTSD (80 % vs. 40 %) while simultaneously being 2.4 times less likely to attempt suicide (17 % vs. 40 %) and 1.5 times less likely to self-injure (67 % vs. 100 %). In both studies, clients in DBT + DBT PE also showed large pre-post improvements in dissociation, depression, anxiety, guilt, shame, and social and global functioning, and, in the RCT, these improvements were larger in DBT + DBT PE than in DBT. In the RCT, 80 % of DBT + DBT PE completers versus 0 % of DBT completers both reliably improved and reached a normative level of functioning in terms of global symptom severity at posttreatment.
17.1.4 Summary
In sum, five treatments for PTSD have been shown to be effective in reducing PTSD and associated problems for individuals with comorbid BPD. These treatments vary not only in their general approach (single diagnosis, phase based, and integrated) but also in the types of trauma-focused interventions used (exposure, cognitive therapy, narration), types of trauma they were designed to treat (adult assaults, childhood sexual abuse, and multiple traumas), length (ranging from 9 to 52 sessions), and treatment setting (inpatient, residential, and outpatient). Of particular note, although each of these treatments has been evaluated among clients with BPD/BPC, most have excluded individuals with problems common in severe BPD, such as acute suicidality (Clarke et al. 2008; Feeny et al. 2002; Pabst et al. 2012), recent life-threatening behavior (Bohus et al. 2013), recent suicidal behavior (Clarke et al. 2008; Feeny et al. 2002; Pabst et al. 2012), recent NSSI (Clarke et al. 2008; Feeny et al. 2002), ongoing abuse (Clarke et al. 2008; Feeny et al. 2002), and/or substance dependence (Clarke et al. 2008; Feeny et al. 2002; Pabst et al. 2012; Bohus et al. 2013). Thus, their generalizability to BPD clients with these co-occurring problems is unknown. To date, only one treatment has been developed specifically for individuals with co-occurring BPD and PTSD that has included clients with each of these severe co-occurring problems (Harned et al. 2012, 2014). However, research on treatments for co-occurring BPD and PTSD is generally limited, and additional research is needed to replicate and extend these findings in larger and more representative samples of clients with this challenging comorbidity.
17.2 Special Challenges
Treatment of clients with both PTSD and BPD is often complicated by a variety of factors. Although the issues described below are likely to interfere with effective treatment of any kind, these factors are highlighted as posing particular challenges to clinicians engaging in trauma-focused treatment.
17.2.1 Suicide and Self-Injury
Suicidal behavior and NSSI are often considered a “hallmark” feature of BPD, with 60–70 % reporting a history of multiple suicide attempts and NSSI episodes (Zanarini et al. 2008) and 8–10 % dying by suicide (Pompili et al. 2005). Among individuals with BPD, these behaviors are often precipitated by PTSD symptoms (Harned et al. 2010) and most often function to provide relief from unpleasant emotions (Brown et al. 2002). As trauma-focused treatments often elicit intense emotions and can cause initial increases in PTSD symptoms before improvement is seen (Nishith et al. 2002), it is understandable that clinicians and BPD patients may both be wary of the potential for a recurrence of these behaviors during PTSD treatment. Moreover, it is possible that fears of intense emotion may prevent therapists and clients alike from fully allowing trauma-related emotions to be experienced, thus potentially decreasing the effectiveness of treatment. Additionally, if suicidal and self-injurious behaviors function as an escape from trauma-related emotions, then the opportunity to learn that these painful emotions can be tolerated without escaping will likely be missed. To address these factors, all of the treatments reviewed above require clients to be abstinent from serious suicidal behavior for a period of 2–4 months before beginning trauma-focused treatment, and most also require abstinence from NSSI. In addition, several treatments include an initial stabilizing phase to help suicidal and self-injuring clients learn the skills necessary to control these behaviors prior to initiating trauma-focused interventions.
17.2.2 Emotion Dysregulation
The regulation of emotion is a complex process involving multiple components of the emotional system (e.g., cognitive interpretation, physiological sensation, behavioral expression). Dysregulation can occur at any point in the system. The biosocial theory of BPD proposed in DBT is that it is the transaction between an emotionally vulnerable biology and an invalidating environment (which may include childhood abuse and trauma) that leads to the pervasive disruption of the emotion regulation system that is central to BPD (Linehan 1993a). According to the theory, emotional vulnerability is defined as having a lowered threshold for emotionally salient cues, increased emotional reactivity, and a slow return to emotional baseline. The emotion dysregulation exhibited by BPD individuals is further intensified by the presence of PTSD (Harned et al. 2010; Marshall-Berenz et al. 2011) and can complicate PTSD treatment in several ways. Dysregulated emotions can lead to over-engagement during trauma-focused treatment, although more often the dysregulated emotional system yields emotional withdrawal and suppression of emotional experience. Either extreme deviates from optimal emotional engagement and is likely to interfere with treatment response. Emotion dysregulation of BPD patients is extensive and typically extends across the entire emotional spectrum. As such, intense non-fear emotions such as sadness, anger, and shame may equally interfere with treatment effectiveness. To address this, several treatments reviewed above teach clients behavioral skills (e.g., emotion regulation, distress tolerance) prior to beginning trauma-focused treatment and coach clients to use these skills as needed to increase or decrease emotional intensity during trauma-focused interventions.
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