Psychotherapy for posttraumatic stress disorder in patients with borderline personality disorder: a systematic review and meta-analysis of its efficacy and safety

Abstract

Background: Posttraumatic stress disorder (PTSD) is common in patients with personality disorders. This comorbidity is accompanied by a lower quality of life, and a higher risk of suicide attempts than patients with only one of these diagnoses. Objective: The aim of this systematic review and meta-analysis was to evaluate the scientific evidence of the efficacy of PTSD treatments for this population. Method: A literature search was performed from 1946 through June 2020. Standardized mean effect sizes of psychotherapy for PTSD were computed. Results: The literature search revealed that psychotherapy was the only intervention that was systematically explored. Fourteen studies were included. In 12 of these studies solely patients with borderline personality disorder participated. Analysis of the four RCTs showed a significant, moderate to high standardized effect size for reducing PTSD symptom severity (Hedges' g = 0.54), with effects being maintained at least 3 months (Hedges' g = 0.82). Effect sizes for all studies were also significant, with moderate to high standardized values for symptoms of PTSD (Hedges' g = 1.04). PTSD improvements were again maintained at 3-month follow-up and beyond (Hedges' g = 0.98). In addition, a significant decrease in symptoms of depression, anxiety, borderline symptoms, and PTSD in patients with borderline personality disorder could be revealed for all studies (Hedges' g 0.48-1.04). No increase in self-injurious behaviour, suicide attempts, or hospitalization was observed, while the mean weighted dropout rate during PTSD treatment was 17%. Conclusions: Psychotherapy for PTSD is efficacious and safe for patients with borderline personality disorder and should not be withheld from these vulnerable individuals. Psicoterapia para el trastorno de estres postraumático en pacientes con trastorno límite de la personalidad: una revisión sistemática y metanálisis de su eficacia y seguridad Antecedentes: El trastorno de estrés postraumático (TEPT) es común en pacientes con trastornos de la personalidad. Esta comorbilidad se acompaña de una menor calidad de vida y un mayor riesgo de intentos de suicidio que los pacientes con solo uno de estos diagnósticos. Objetivo: El propósito de esta revisión sistemática y metanálisis fue evaluar la evidencia científica de la eficacia de los tratamientos de TEPT para esta población. Método: Se realizó una búsqueda bibliográfica desde 1946 hasta junio de 2020. Se calcularon los tamaños de efecto promedio estandarizados de la psicoterapia para el TEPT. Resultados: La búsqueda de la literatura reveló que la psicoterapia fue la única intervención explorada sistemáticamente. Se incluyeron catorce estudios. En doce de estos estudios participaron únicamente pacientes con trastorno límite de la personalidad. El análisis de los cuatro ECA mostró un tamaño de efecto estandarizado significativo, moderado a alto, para reducir la gravedad de los síntomas de TEPT (Hedges' g = 0.54), con efectos que se se mantenían al menos tres meses (Hedges' g = 0.82). Los tamaños del efe...

Does EMDR Therapy Have an Effect on Memories of Emotional Abuse, Neglect and Other Types of Adverse Events in Patients with a Personality Disorder? Preliminary Data

“…Our findings are in line with research focusing on the effectiveness of EMDR therapy in different patient groups both with [12,34] and without PTSD [35,36]. Regarding the latter, a study that investigated the effectiveness of 6-8 sessions of EMDR therapy among 26 patients diagnosed with a depressive disorder, whose memories involved non-Acriterion traumatic events (i.e., parental neglect, loss, and broken relationships), led to a significant reduction in symptoms of depression and PTSD [36].…”

“…Given the relatively high level of exposure to adverse childhood events in patients with PDs, it could be hypothesized that treating and processing the memories of these events will decrease symptoms and symptom clusters typically associated with PDs, such as problems with regulation of emotions, low self-esteem, social withdrawal, avoidance and mistrust. Indeed, several studies showed that trauma-focused therapy was associated with an improvement of symptoms of comorbid PDs in patients fulfilling the diagnostic criteria of PTSD [ 10 , 11 , 12 ]. However, many individuals with a PD do not meet the diagnostic criteria for PTSD because their memories do not meet the A-criterion of the DSM-5 PTSD classification [ 13 ] that defines the index trauma as ‘exposure to actual or threatened death, serious injury or sexual violence’.…”

Impact of comorbid personality disorders on psychotherapy for post-traumatic stress disorder: systematic review and meta-analysis

“…These results suggest that, although the presence of comorbid PDs does not preclude a good response to PTSD treatment, patients with comorbid PDs benefit less from PTSD treatment than patients without comorbid PDs. The magnitude of our pre- to post-treatment effect size in patients without comorbid PDs ( g = 1.46) was similar to those found in previous PTSD effect studies ( d = 1.43) (Bradley et al, 2005 ) and our pre- to post-treatment effect size in patients with comorbid PDs ( g = 1.16) was comparable to the effect size of a recent meta-analysis on psychotherapy for PTSD in patients with comorbid borderline PD ( g = 1.04) (Slotema et al, 2020 ). It should, however, be noted that visual inspection of the data presented Table 2 shows that the average PTSD symptom severity at post-treatment remained significant in most included studies.…”

“…In addition, a large subgroup of patients with comorbid PDs is excluded from PTSD treatment due to the common confluence of exclusion criteria for suicidality or self-destructive behaviour (American Psychological Association, 2017 ; National Collaborating Centre for Mental Health National Collaborating Centre for Mental Health, 2005 ). Ambiguity in the existing literature with regard to the impact of PDs on PTSD treatment outcome further complicates this issue: while some studies found an association between comorbid PDs and an enhanced risk for dropout (McDonagh et al, 2005 ) as well as a poorer response to treatment (Cloitre & Koenen, 2001 ; Forbes et al, 2002 ; Hembree, Cahill, & Foa, 2004 ; Stalker, Palmer, Wright, & Gebotys, 2005 ), other studies failed to find a relationship between PDs and PTSD treatment outcome (Clarke, Rizvi, & Resick, 2008 ; Feeny, Zoellner, & Foa, 2002 ; Markowitz et al, 2015 ; Tarrier, Sommerfield, Pilgrim, & Faragher, 2000 ; Van Minnen, Arntz, & Keijsers, 2002 ; Walter et al, 2012 ) and a recent meta-analysis concluded that PTSD interventions can be safe and effectively applied in patients with comorbid borderline PD (Slotema, Wilhelmus, Arends, & Franken, 2020 ). Given these inconsistencies, it remains unclear if and to what extent comorbid PDs affect the severity of PTSD symptoms and whether psychotherapies for PTSD can be just as effectively applied in patients with comorbid PDs as in patients without comorbid PDs.…”

Neural correlates of treatment effect and prediction of treatment outcome in patients with PTSD and comorbid personality disorder: study design

“…One study has shown that TFT in patients with PTSD and personality disorders (BPD was excluded) is effective [ 9 ]. There is also evidence that TFT is effective in patients with PTSD+BPD [ 10 ], although a recent meta-analysis shows lower effect sizes for TFT in patients with PTSD and comorbid personality disorders, compared to patients with PTSD-only [ 11 ]. Well-established therapies for BPD and CPD are group-based dialectical behavioral therapy (DBT [ 12 ]) and schema focused therapy (SFT [ 13 ]), respectively.…”