The Combined Treatment of PTSD with Borderline Personality Disorder

Abstract

Psychotherapies are currently the front-line approach to treating individuals with comorbid post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD). Of the available psychotherapeutic treatment options, those that have been evaluated in randomized controlled trials (RCTs) and shown to be efficacious in reducing PTSD among individuals with BPD include: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Dialectical Behavior Therapy (DBT), DBT for PTSD (DBT-PTSD), and DBT with the DBT Prolonged Exposure protocol (DBT + DBT PE). In addition, Narrative Exposure Therapy (NET) has shown preliminary evidence of effectiveness in an open trial. The available research indicates that individuals with a primary diagnosis of PTSD and mild or sub-threshold BPD (e.g., without suicidal or serious self-injurious behavior or other severe comorbidities) can be effectively treated via brief (9–14 session), single-diagnosis treatments such as PE and CPT that focus solely on treating PTSD. PE and CPT appear to be comparably efficacious for individuals with PTSD and mild BPD. Individuals with PTSD and a moderate level of BPD (e.g., active non-suicidal self-injury [NSSI] without recent life-threatening behavior, some significant comorbidities) have shown good outcomes in DBT-PTSD, a 12-week, residential, phase-based treatment that targets comorbid problems (e.g., emotion dysregulation, psychosocial impairment) before and after addressing PTSD. Finally, individuals with PTSD and a severe level of BPD (e.g., with recent and/or acute suicidal behavior, serious NSSI and multiple severe comorbidities) have been effectively treated in longer-term (one year), integrated treatments such as DBT and DBT + DBT PE that concurrently target BPD, PTSD, and other related problems. Of these integrated treatments, DBT + DBT PE appears to be more efficacious than DBT alone in improving PTSD, suicidal and self-injurious behavior, and other trauma-related outcomes among severe BPD patients.