There is a growing body of evidence that examines and attempts to address the challenges of working with a group of individuals presenting with a combination of Borderline Personality Disorder (BPD), Suicidal/Non-Suicidal Self-directed Injury (NSSDI), and PTSD. These symptoms combine to create a cycle that is difficult to break. At a fundamental level, the individual struggles to manage their emotions effectively and can often be impulsive. Impulsive behavior is a reaction to overwhelming emotional experiences and the overwhelming emotion often elicits suicidal/NSSDI behaviors. Individuals with borderline personality disorder and PTSD are at significantly greater risk for self-harm than those with PTSD alone. The major problem with this pattern is that PTSD treatment frequently creates distress, and for those with poor emotional regulation it can lead to self-harm, but the PTSD symptoms need to be treated in order to create greater stability.
Understanding how to prepare your patient for the stress associated with PTSD treatment so they can safely participate has been a significant challenge. Dialectical Behavior Therapy (DBT) has been shown to be a highly effective treatment for reducing self-harm behaviors. There have been recent advances in understanding the various components of DBT, in particular, skills training, which has been highly correlated with a reduction in self-harm. A high-fidelity DBT program is often unavailable or impractical, which has prompted a variety of uncontrolled studies that examined the effectiveness of DBT skills trainings alone, as well as some controlled research studies that attempt to dismantle the components of DBT. These studies have demonstrated potential for the skills training component to be used as a stand-alone treatment.
Additionally, Melanie Harned, Ph.D., has developed a combined DBT- Prolonged Exposure (DBT-PE) protocol to treat individual with BPD and PTSD. The protocol initially focuses on developing distress management skills, ensuring that the patient is able to utilize the skills when they experience triggers that frequently result in urges for self-harm. Treatment only moves forward to address trauma symptoms once the patient has reasonably demonstrated an ability to remain safe during trauma-focused therapy. This is an important advance in treatment because it provides a framework in which these individuals can receive the PTSD treatment they need.
However, it is extremely important to consider the time frame and course for this treatment process. Published case studies seem to indicate a 1-2 year course of weekly treatment with a reasonable likelihood of re-emergence of self-harm behavior. In the event of this occurrence, PTSD treatment is paused, the self-harm behaviors are addressed and PTSD treatment resumes when it seems clear the patient is able to safely participate.
These advances provide greater insight into the mechanisms that are involved in treating this population and the interventions that may be effective. It is my hope that greater awareness of these advances will promote systems and structures that enable these individuals to receive effective treatment. The references provided examine these issues in great depth and are great resources for developing programs and structures to address this patient population.
Jeffery Mann, Psy.D., is the Deployment Behavioral Health Psychologist at Naval Medical Center San Diego.
Granato, H.F., Wilks, C.R., Miga, E.M., Korslund, K.E., Linehan, M.M. (2015). The use of Dialectical Behavior Therapy and Prolonged Exposure to treat comorbid dissociation and self-harm: The case of a client with Borderline Personality Disorder and Posttraumatic Stress Disorder. Journal of Clinical Psychology: In session, 7(8), 805-815.
Harned, M.S. & Linehan, M.M. (2008). Integrating Dialectical Behavior Therapy and Prolonged Exposure to treat co-occurring Borderline Personality Disorder and PTSD: Two Case Studies. Cognitive and Behavioral Practice, 15, 263-276. DOI: 10.1016/j.cbpra.2007.08.006
Harned, M.S, Korslund, K.E. & Linehan, M.M. (2014). A pilot randomized controlled trial of Dialectical Behavioral Therapy with and without the Dialectical Behavioral Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7-17. DOI: 10.1016/j.brat.2014.01.008
Linehan, M.M., Korslund, K.E., Harned, M.S., Gallop, R.J., Lungu, A., Neacsiu, A.D., McDavid, J., Comtois, K.A., Murray-Gregory, A.M. (2015). Dialectical behavior therapy for high suicide risk in individuals with Borderline Personality Disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5); 475-482. DOI: 10.1001/jamapsychiatry.2014.3039
Scheiderer, E., Carlile, J.A., Aosved, A.C., Barlow, A. (2017). Concurrent Dialectical Behavior Therapy and Prolonged Exposure reduces symptoms and improves overall quality of life for a veteran with Posttraumatic Stress Disorder and Borderline Personality Disorder. Clinical Case Studies, 17, 216-233.
Valentine, S.E., Bankoff, S.M., Poulin, R.M., Reidler, E.B., & Pantalone, D.W. (2015). The use of Dialectical Behavior Therapy skills training as a stand-alone treatment: A systemic review of the treatment outcome literature. Journal of Clinical Psychology, 71, 1-20. DOI: 10.1002/jclp.22114