The Missing Link: Treating Trauma Disorders in individuals with BPD
By Kelly Turner, LCSW
Trauma Disorders are a growing problem in the United States. Recent research indicates that in The United States, 1.8% of men and 5.2% of women are diagnosed with Post Traumatic Stress Disorder (PTSD) (Kessler et al., 2005). The prevalence of PTSD among those diagnosed with Borderline Personality Disorder (BPD) are much higher. In a recent study the comorbidity of PTSD in individuals diagnosed with PTSD was 30.2% (Pagura et al., 2010). At the same time, Dialectical Behavior Therapy (DBT) was showing poor remissions rates in PTSD with outcomes as low as 35% remission rates (Harned et al., 2008).
We know that PTSD symptoms are related to BPD symptoms in individuals with comorbid diagnosis. The problem the field has been presented with is that evidence based treatments for PTSD come with exclusion criteria that include risks of suicide, self-injury, and substance use disorders. These exclusion criteria have led clinicians to exclude BPD clients from evidence based trauma treatments. As clinicians, we were left with an individual that needed trauma treatment, but the belief was the treatment was not safe for them to participate in, yet we were struggling to make progress in treatment not being able to address the PTSD.
Dr. Melanie Harned along with Dr. Marsha Linehan pioneered a treatment for these individuals that combined DBT along with Prolonged Exposure (PE), an effective treatment for trauma developed by Dr. Edna Foa. They combined the self-monitoring strategies in DBT (diary cards and pre/post session ratings) with the exposure principles in PE. Initial studies indicate that PE did not increase suicidal and non-suicidal self-injury in individuals diagnosed with PTSD and BPD (Harned, Korslund, Foa, & Linehan, 2012). Although there are no clear guidelines on when to start PE with these individuals, recent research continues to indicate that trauma treatment can begin much earlier than initially thought. The combination of DBT and PE is proving to be the missing link clinicians have been looking for in treating these two comorbid and complex illnesses.