Effects of intensive trauma-focused treatment of individuals with both post-traumatic stress disorder and borderline personality disorder

Underdiagnosis of Posttraumatic Stress Disorder Among Outpatients With Personality Disorders in Clinical Practice Despite the Use of a Diagnostic Instrument

While existing literature suggests that posttraumatic stress disorder (PTSD) is frequently undetected in routine clinical practice, the detection rate of PTSD in patients with a personality disorder (PD) has not been investigated. This study examined the point prevalence of PTSD and frequency of trauma-focused treatment in 204 outpatients with a PD. Data were derived from electronic patient files. Compared to the mean weighted prevalence of PTSD in the literature, the Mini International Neuropsychiatric Interview Plus (MINI-Plus) found lower rates of PTSD for the entire sample (29.2%), but not separately for patients with borderline PD (BPD; 33.3%) and patients with other PDs (26.9%). In addition, PTSD diagnoses following intake were less prevalent for PD patients overall (18.6%), BPD patients (27%), and patients with other PDs (13.8%). The present study provides preliminary evidence that PTSD might be underdiagnosed and consequently unmanaged in PD patients in clinical practice, suggesting that the recognition of PTSD among patients with PD needs improvement.

Long-term effects of dialectical behaviour therapy for posttraumatic stress disorder and cognitive processing therapy 9 months after treatment termination

Background: The complexity of posttraumatic stress disorder (PTSD) symptoms related to childhood abuse (CA) present challenges for effective psychotherapeutic treatment. Consequently, there is great interest in the long-term effectiveness of psychological treatments for this population.Objective: This study aims to investigate the long-term outcomes of Dialectical Behaviour Therapy for PTSD (DBT-PTSD) and Cognitive Processing Therapy (CPT) 9 months after treatment termination.Method: This is a long-term analysis from a randomised-controlled trial of DBT-PTSD versus CPT (registration number DRKS00005578). Initially, 193 individuals with CA-related PTSD were randomly allocated to receive either DBT-PTSD (n = 98) or CPT (n = 95). The primary outcome the Clinician-administered PTSD-Scale for DSM-5 (CAPS-5) was administred at baseline, treatment completion (15 months post-randomization) and at the 9-month follow-up. Secondary outcomes included self-reported PTSD severity (PCL-5), dissociation (DSS), severity of borderline symptoms (BSL-23), and psychosocial functioning (GAF).Results: No significant changes were observed in the primary (CAPS) and all other outcomes from post-intervention to 9-months follow-up in both the DBT-PTSD (CAPS: Mpost  = 15.60, Mfollow-up  = 14.93) and CPT group (CAPS: Mpost = 18.80, Mfollow-up = 17.41). Between-group analyses at 9-months follow-up were significantly in favour of DBT-PTSD compared to CPT with small to medium effect sizes on all outcomes ranging from d = 0.35 on the CAPS to d = 0.57 on the BSL-23 and GAF.Conclusions: Our results indicate that treatment effects of psychotherapy addressing complex presentations of PTSD persist 9 months after treatment termination. In addition, the superiority of DBT-PTSD as compared to CPT found at treatment termination, was confirmed at 9-months follow-up.Trial registration: German Clinical Trials Register identifier: DRKS00005578..

Trauma-focused and personality disorder treatment for posttraumatic stress disorder and comorbid cluster C personality disorder: a randomized clinical trial

Background: Posttraumatic stress disorder (PTSD) is associated with high rates of cluster C personality disorders (PD), which may negatively affect PTSD treatment. It is unknown whether concurrent treatment for PTSD and comorbid PD leads to superior treatment effects, compared to standard trauma-focused treatment.Objective: The objective was to test the efficacy of adding personality disorder treatment (group schema therapy; GST) to individual trauma-focused treatment (imagery rescripting; ImRs).Method: A two-arm randomized clinical trial (1:1 allocation ratio) was conducted between 2018 and 2023 at two sites of a mental health institution in the Netherlands. Raters were blind to treatment allocation. Adult outpatients with PTSD and comorbid cluster C personality disorders were randomized to receive either ImRs (12-18 sessions) or ImRs + GST (12-18 ImRs + 52-58 GST). The main outcome was PTSD severity one year after start of treatment measured with the Clinician-Administered PTSD Scale for DSM-5.Results: Of 130 patients (mean [SD] age = 40.6 [11.2], 110 [85%] females), 66 were assigned to ImRs and 64 to ImRs + GST. At 12 months, there were large decreases in PTSD severity (dImRs = 2.42, 95%CI = 1.97-2.87; dImRs + GST = 2.44, 95%CI = 1.99-2.90), but there was no significant difference between conditions (d = 0.02, 95%CI = -0.33-0.36, p = .944). Reductions in personality disorder symptoms and all other secondary outcomes were observed in both conditions. There were no significant differences between conditions on any of the secondary outcomes at 12 months.Conclusion: The more intensive concurrent trauma-focused and personality disorder treatment (ImRs + GST) was not superior to trauma-focused treatment alone (ImRs) for patients with PTSD and comorbid CPD. This suggests that trauma-focused treatment is the preferred primary treatment in patients presenting with both internalizing personality disorder and PTSD, reserving the stepping up to more intensive psychotherapy aimed at the personality disorder as a second line of treatment.Trial registration: ClinicalTrials.gov identifier: NCT03833531.

Impact of three variants of prolonged exposure therapy on comorbid diagnoses in patients with childhood abuse-related PTSD

Recent studies indicated that Prolonged Exposure (PE) is safe and effective for posttraumatic stress disorder (PTSD). It is unclear whether PE also leads to a reduction in comorbid diagnoses. Data from a large randomized controlled trial (N = 149) on the effects of three variants of PE for PTSD were used. We examined the treatment effects on co-morbid diagnoses of depressive, anxiety, obsessive compulsive, substance abuse, psychotic, eating and personality disorders in a sample of patients with PTSD related to childhood abuse. Outcomes were assessed with clinical interviews at baseline, post-treatment and at 6- and 12-month follow-up. All variants of PE led to a decrease from baseline to post-treatment in diagnoses of depressive, anxiety, substance use and personality disorders. Improvements were sustained during follow-up. We found an additional decrease in the number of patients that fulfilled the diagnostic criteria of a depressive disorder between 6- and 12-month follow-up. No significant changes were observed for the presence of OCD, psychotic and eating disorders. Findings suggest that it is effective to treat PTSD related to childhood abuse with trauma-focused treatments since our 14-to-16 weeks PE for PTSD resulted in reductions in comorbid diagnoses of depressive, anxiety, substance use and personality disorders.

Exhausting, but necessary: the lived experience of participants in an intensive inpatient trauma treatment program

Background

Intensive inpatient treatment programs have shown robust results in the treatment of post-traumatic stress disorder (PTSD). How patients experience this treatment program and what changes they experience as a result of the treatment have, however, only scarcely been explored through qualitative studies.

Objective

This study aimed to explore the lived experience of participants in an intensive inpatient trauma treatment program. Our research questions were as follows: how do patients experience intensive trauma-focused treatment? How do they experience possible changes related to participating in the treatment program?

Methods

Six patients diagnosed with PTSD with significant comorbidities, who recently participated in an intensive 2-week (4 + 4 days) inpatient trauma treatment program with prolonged exposure (PE), eye movement desensitization and reprocessing (EMDR), and therapist rotation (TR), were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach.

Results

Our analysis resulted in five main themes: (1) the need to feel safe; (2) the benefits of many and different therapeutic encounters; (3) variable experience with elements of treatment; (4) intensity; and (5) experienced change. Our results suggest that feeling safe within the framework of the treatment program facilitated the treatment process. Many and different therapeutic encounters, both through TR and with ward staff, contributed to experienced change. All participants described the intensity as facilitative to trauma processing. However, most participants also describe often feeling too overwhelmed to benefit from all elements of the treatment program.

Conclusions

Our findings suggest that participants experience the overall treatment program as beneficial and contributing to experienced change. Participants described the intensity of the program as exhausting, but necessary. Most did, however, report at times of being too overwhelmed to benefit from elements of the program. Consequently, our results prompt us to question the optimal level of intensity.

Trial registration

ClinicalTrials.gov identifier: NCT05342480. Date of registration: 2022-04-22.

Feasibility of EMDR toward Personality Functioning in Older Adults with PTSD

OBJECTIVES

Severe posttraumatic stress disorder (PTSD) in older adults (≥60 years) has been found to be associated with maladaptive personality functioning and personality disorders (PD). Emerging evidence in adults supports that reprocessing adverse events with Eye Movement Desensitization and Reprocessing (EMDR) could improve personality functioning and reduce full PDdiagnosis.

METHODS

A multicenterfeasibilitystudy in 24 older PTSD-patients receiving weekly EMDR-sessions for either 3, 6 or 9 months. A linear-mixed-model was used with personality functioning (SIPP-SF) as dependent variable and time, PTSD-severity (CAPS-5), and "othertreatment" as predictor variables. Secondary, pre- and posttreatment percentages were calculated for the PDspresence.

RESULTS

Symptom changes over time showed a significant influence of CAPS-5 on SIPP-SF (b = -1.40, 95% CI=[-2.48 to -0.33], p = .012), no significant effect of time for total SIPP-SF, and a significant improvement of SIPP-SF "identityintegration"-scale over time (b = 9.20, 95% CI=[0.97-17.42], p = .029). There was a marginal significant effect of "othertreatment" (b = 8.42, 95% CI=[-0.30-17.13], p = .058). There was 31% full PDs-decrease.

CONCLUSIONS

Observed improvements in personality functioning from pre to post EMDRtreatment were explained by PTSD-severity. Identityintegration improved significantly over time. Results suggest that participants with "othertreatment" showed more severe baseline-pathology and thus lower personality functioning.

CLINICAL IMPLICATIONS

EMDR, in addition to being a feasible treatment option for older adults with PTSD, improves personality functioning and reduces the presence of PDs over time.'

Trauma-focused treatment of a client with Complex PTSD and comorbid pathology using EMDR therapy

OBJECTIVE

Complex post-traumatic stress disorder (CPTSD) is a classification within the International Classification of Diseases, 11th Revision (ICD-11) that, besides the DSM-5 symptom clusters of post-post-traumatic stress disorder (PTSD), includes the presence of negative self-concept, difficulties in regulating emotions and relationship skills. The purpose of the present study was to provide guidance on how to deliver Eye Movement Desensitization and Reprocessing (EMDR) therapy in the context of CPTSD, based on current clinical knowledge and the latest scientific research findings.

METHOD

This paper describes the treatment of a 52-year-old woman with CPTSD and borderline personality disorder for which immediate trauma-focused EMDR therapy was used.

RESULTS

First, a description of what EMDR therapy entails and some important treatment strategies that the therapist may employ to assist in trauma-focused treatment of clients with CPTSD using EMDR therapy are outlined.

CONCLUSION

The treatment results are in line with mounting evidence supporting the notion that EMDR therapy is a safe and potentially effective treatment alternative for individuals with CPTSD or personality problems.

The AIP model as a theoretical framework for the treatment of personality disorders with EMDR therapy

Research has shown that the impact of traumatic events and circumstances on individuals is cumulative and potentially has a wide range of harmful consequences, including negative consequences on mental health. One such consequence is the development of a personality disorder, a persistent mental condition characterized by a pronounced pattern of difficulties in impulse control, emotional regulation, cognitive functions, self-esteem, and interpersonal relationships. A wide array of studies indicates that the personal history of individuals with a personality disorder is often marked by exposure to traumatic events or other types of adverse childhood experiences (ACEs). Because existing treatments for personality disorders are usually long and costly, it is essential to continue exploring alternative and complementary interventions. Nowadays, knowledge and clinical experience in regard to personality disorders have been gained in addressing ACEs by processing memories of these events through eye movement desensitization and reprocessing (EMDR) therapy. In this paper, we present a theoretical framework for this treatment approach, based on Shapiro's Adaptive Information Processing (AIP) model, describe its current empirical basis, and provide guidance on how to formulate a useful case conceptualization that can serve as a basis for the treatment of personality disorders with EMDR therapy. This approach is illustrated with a case example.

Case report: Brief, intensive EMDR therapy for borderline personality disorder: results of two case studies with one year follow-up

Background

Exposure to adverse childhood events plays an important role in the development of borderline personality disorder (BPD). Emerging evidence suggests that trauma-focused therapy using eye movement desensitization and reprocessing (EMDR) can be beneficial for patients with BPD symptoms. To date, the effects of brief, intensive EMDR treatment for this target group have not been investigated in this population.

Objective

This study aimed to evaluate the effects of a brief and intensive trauma-focused therapy course using EMDR therapy in two patients diagnosed with BPD who did not fulfill the diagnostic criteria for post-traumatic stress disorder (PTSD). It was hypothesized that this approach would be associated with a decline in the core symptoms of BPD, and that this would have an enduring long-term effect on patients' diagnostic status.

Method

Ten sessions of EMDR therapy were carried out across four consecutive treatment days, with the aim of processing patients' core adverse childhood experiences. Both A-criterion-worthy memories (without intrusive reliving) and non-A-criterion-worthy memories that were considered responsible for the patients' most prominent symptoms were targeted. The effects of EMDR therapy on trauma symptom severity and BPD diagnostic status (as established by the Structured Clinical Interview DSM-5) were determined. Additionally, the effects on psychological distress, quality of life, and difficulties in emotion regulation were determined at intake, post-treatment, and at 3-, 6-, and 12-months follow-up.

Results

Both patients showed a strong decline in psychological distress and difficulties in emotion regulation, and reported an improvement in their quality of life. At post-treatment, and at 3-, 6-, and 12-months follow-up they no longer met the DSM-5 criteria for BPD.

Conclusion

The findings of this small case study are in line with mounting evidence that a brief track of intensive trauma-focused therapy can result in long-term remission in patients with BPD. EMDR therapy seems to be a promising treatment approach for patients with BPD; however, the results need to be replicated in clinical trials.

Is it safe enough? A pilot feasibility study of an 8-day intensive treatment for severe PTSD

Intensive treatments for posttraumatic stress disorder (PTSD) are gaining increased research support. Treatment models targeting Complex PTSD and previously treatment-resistant PTSD have shown a good effect. A pilot study was performed to assess the feasibility of an 8-day intensive treatment program for severe PTSD in a Swedish public healthcare setting. Eleven participants completed treatment, and overall, the reduction in PTSD symptoms was considerable. Also, loss of diagnosis at 3-month follow-up was 100%. No adverse events occurred, and no elevation of suicidal intentions was reported. Symptom exacerbation could not be observed in the data and dropout due to the intensity of the treatment format did not occur. Based on these positive results, it is recommended that further research with larger samples is conducted. If found safe and effective, the 8-day treatment program could be an important addition to psychiatric healthcare.