Borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) are complex mental health disorders that present challenges in both diagnosis and treatment. Data shows the following prevalence of these two disorders in the adult population.
Prevalence of BPD and PTSD
- Borderline personality disorder (BPD):
- Current diagnosis of BPD: 1.6%
- Ever diagnosed with BPD: 5.9%
- Post-traumatic stress disorder (PTSD):
- Current diagnosis of PTSD: 4.7%
- Ever diagnosed with PTSD: 6.1 %
In addition, data shows the following association between BPD and PTSD.
Prevalence of Comorbid BPD and PTSD
- Among patients with PTSD diagnosis:
- 24.2% have a BPD diagnosis
- Among patients with BPD diagnosis:
- 30.2% have a PTSD diagnosis
When an individual receives a diagnosis for more than one disorder at a time, it’s called comorbidity, and they receive what’s called comorbid diagnoses. That’s one thing that makes both BPD and PTSD difficult to treat. However, treatment for both BPD and PTSD can be effective. Evidence shows the following approaches can help patients with comorbid BPD and PTSD.
Evidence-Based Treatment for Comorbid BPD and PTSD
- Dialectical behavior therapy (DBT) for posttraumatic stress disorder (DBT-PTSD):
- Effective for people with PTSD and mild BPD
- Prolonged exposure therapy + cognitive processing therapy (CPT):
- Effective for people with PTSD and moderate BPD
Considering the severity of both disorders, and the cumulative severity when the two disorders are comorbid, there is a surprising lack of definitive evidence on effective treatment for comorbid BPD and PTSD.
In this article, we’ll discuss the results of meta-analysis published in 2021 called “Optimizing Treatment For Comorbid Borderline Personality Disorder and Posttraumatic Stress Disorder: A Systematic Review Of Psychotherapeutic Approaches and Treatment Efficacy” that fills the lack of scholarship on this topic. The authors examine the following:
- BPD-specific treatments
- Trauma-focused treatments
- Non-trauma-focused treatments for PTSD
- Stage-based treatments for BPD-PTSD
We’ll share what these researchers found, below. First, though, we’ll define BPD and PTSD, and address the reasons why seeking new treatment modalities for these disorders is important. We’ll start with borderline personality disorder (BPD).
What is Borderline Personality Disorder (BPD)?
Here’s how the National Institute of Mental Health (NIMH) describes BPD:
“Borderline personality disorder is a mental illness that severely impacts a person’s ability to regulate their emotions. This loss of emotional control can increase impulsivity, affect how a person feels about themselves, and negatively impact their relationships with others.”
That’s the first thing to understand about BPD: it impacts emotional regulation and impulsivity, which in turn impacts interpersonal relationships. The NIMH continues:
“People with borderline personality disorder may experience intense mood swings and feel uncertainty about how they see themselves. Their feelings for others can change quickly, and swing from extreme closeness to extreme dislike.”
That’s the second thing to understand about BPD: the mood swings are intense and can change almost immediately, with no clear warning or trigger. These changes are related to how people with BPD see the world. The NIMH clarifies this component of BPD symptoms:
“These changing feelings can lead to unstable relationships and emotional pain. People with borderline personality disorder also tend to view things in extremes, such as all good or all bad. Their interests and values can change quickly, and they may act impulsively or recklessly.”
It’s clear that BPD is distressing and disruptive for everyone involved: the patient, their family, and anyone associated with them. One thing that’s difficult to understand is that the our latest understanding of BPD is that the primary issue for most patients – and what leads to some of the most challenging behavior – is an intense fear of abandonment by those they love the most.
To meet clinical criteria for BPD, the National Institutes of Health (NIH) and the Diagnostic and Statistical Manual of Mental Disorders Volume 5 (DSM-5) indicates an individual must show at least five of the following symptoms.
Clinical Criteria for BPD Diagnosis
- Extreme/frantic efforts to avoid real or imagined abandonment.
- Unstable, intense interpersonal relationships that alternate between idealization and devaluation
- Unstable self-image or distorted sense of self
- Impulsivity in at least two areas that can cause harm, aside from suicidal ideation:
- substance abuse
- Unsafe driving
- Risky sex
- Binge eating
- Emotional instability characterized by high reactivity/changeability of mood, i.e. periods of extreme mood that last days or more
- Persistent feelings of emptiness
- Intense anger with no identifiable appropriate cause
- Problems controlling anger:
- Temper tantrums
- Persistent anger
- Frequent or recurring physical fights
- Temporary paranoid ideation
- Temporary dissociative symptoms
People diagnosed with borderline personality disorder often receive diagnoses for other mental health disorders aside from PTSD, which we mention above.
BPD and Other Mental Health Disorders: Additional Complications
Evidence shows high rates of comorbidity with other mental health disorders. These comorbidities increase challenges associated with diagnosis and treatment.
BPD: Common Comorbidities
- Mood disorders: 80% to 96%
- Anxiety disorders: 88%
- Substance abuse disorders: 64%
- Eating disorders: 53%
- Attention deficit hyperactivity disorder (ADHD): 10% to 30%
- Bipolar disorder: 15%
- Somatoform disorders (physical symptoms with no clear physical cause): 10%
Despite the intensity of the disorder and the substantial complications and comorbidities, most people with BPD do not require hospitalization. However, certain situations may require emergency inpatient support, including:
- Imminent risk of lethal behaviors
- Extreme suicidal ideation or impulsivity
- Severe stress resulting in:
- Intense negative thoughts
- Short-term psychosis
- Escalating NSSI (non-suicidal self-injury)
- Extreme/escalating substance use, misuse, or disordered use
Common complications associated with BPD that may not lead to inpatient psychiatric hospitalization include:
- Engaging in risky behavior
- Alcohol and drug misuse
- Attenuated academic achievement
- Loss of employment
- Legal problems
- Inability to form stable, fulfilling relationships
- Suicide attempts
These complications associated with BPD may cause people unfamiliar with the disorder to assume the long-term prognosis is always negative. However – as counterintuitive as this may seem – that’s not necessarily the case with BPD.
BPD Over Time: Outcomes
The intense and volatile nature of the disorder is also complicated by the results of a long-term study on 290 patients with BPD. Researchers followed patients over 16 years and checked in every two years. Patients in the study showed the following remission rates:
- 2 years: 35% remission
- 10 years: 91% remission
- 16 years: 99% remission
However, the research team observed that remission was associated with decreased social interactions and connections. They theorized that remission may be related to a lack of social contact, rather than an increase in productive social and relationship skills. Nevertheless, the researchers identified factors associated with remission, including:
- Absence of comorbid psychiatric disorders
- Absence no childhood sexual abuse
- No history of family substance abuse
As the information above shows, BPD is a complex condition with a challenging symptom profile that follows and atypical progression over time. That’s what makes it difficult to treat, and that’s why we spent significant time discussing the disorder. That’s also the reason the data in the article we’ll discuss in a moment is helpful. Before we look at the latest data on treating comorbid BPD and PTSD, let’s define exactly what we mean by PTSD.
What is Post-Traumatic Stress Disorder (PTSD)?
The American Psychiatric Association (APA) defines PTSD as follows:
“Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances. An individual may experience this as emotionally or physically harmful or life-threatening and may affect mental, physical, social, and/or spiritual well-being.”
Doctors initially identified and defined PTSD in members of the armed forces who displayed symptoms upon returning home from combat in the first and second world wars. Over the past several decades, experts in mental health and treatment have identified a wide range of experiences that can lead to PTSD, which we list below.
Trauma Associated with Subsequent PTSD
- Sexual assault/rape
- Any violent assault
- Significant injury or major accident
- Physical, emotional, or sexual abuse during childhood
- Emotional or physical neglect during childhood
- Natural disasters
- Witnessing the severe injury or death of another person
Every person who experiences traumatic events like those listed above does not develop PTSD. However, data shows that around 20 percent or people who report experiencing these types of trauma go on to develop PTSD or show PTSD symptoms later in life.
Now let’s look at the most common symptoms of PTSD.
Symptoms of PTSD
- These refer to unwanted, intrusive thoughts or memories. These may include:
- Memories of the trauma
- Nightmares
- Insomnia
- People with PTSD work to avoid reminders of their trauma. Avoidance behavior includes:
- Never talking or thinking about the event
- Pretending the trauma never occurred
- Never going places that evoke memories of feelings associated with the trauma
- Refusing to talk to or interact with people associated with the trauma
- Negative thinking and feeling. People with PTSD experience altered patterns of thought and emotion related to their trauma. These may include:
- Constant sadness
- Persistent hopelessness
- Low self-esteem/low image of self
- Persistent fatigue
- Excessive alcohol or substance use
- Heightened physical and emotional reactivity. This is called hyperarousal. In many cases, PTSD causes atypical physical and emotional reactions to typical events, including:
- Becoming very easily frightened or startled
- Persistent sense of being on edge
- Expecting harm or danger any moment
- Dangerous activity, including alcohol/substance use, unsafe driving, and risky sexual activity
- Unusual or excessive anger in response to typical stimuli
- Feelings of shame
Like BPD, the symptom profile of PTSD can cause significant disruption for patients and significant challenges in treatment. However, evidence shows treatment for PTSD can be effective. Therapeutic modalities that help people manage the symptoms of PTSD include:
- Cognitive Behavioral Therapy (CBT)
- Trauma-focused CBT
- Prolonged Exposure (PE) Therapy
- Eye Movement Desensitization and Reprocessing (EMDR)
Now we’re ready to look at the results of the study we introduce in the beginning of this article, which will synthesize elements of all the information we share above – and give us clues about the new approaches to treating comorbid BDP and PTSD.
Treating Comorbid BPD and PTSD: What Works?
The study is important because it’s a large-scale analysis of all the available peer-reviewed data on treating comorbid BPD and PTSD. The research team identified over 2,000 potential articles to analyze, and after a rigorous selection process, chose to focus on 21 studies with data from over 1,000 patients with comorbid BPD and PTSD. Within these studies they examined both the methods and outcomes for BPD-specific treatments, trauma-focused treatments, non-trauma-focused treatments for PTSD, and stage-based treatments for comorbid BPD-PTSD.
Here’s what they found.
BPD Specific Treatments
In patients with BPD and PTSD:
- Patients with PTSD reported higher frequency of self-harm, but presence of PTSD not increase likelihood of self-harm
- PTSD was not associated with increased BPD severity
- Dialectical behavior therapy (DBT) alone did not improve outcomes for people with BPD or PTSD
- Outpatient DBT + trauma focused treatment improved outcomes for people with BPD and PTSD
- Residential DBT-informed BPD-specific treatment improved PTSD outcomes for people with BPD and PTSD
Trauma-Focused Treatments
In patients with BPD and PTSD:
- After trauma-focused residential treatment, patients with BPD and PTSD showed:
- Positive outcomes with eye movement desensitization and reprocessing (EMDR) treatment
- Improvement with prolonged exposure (PE) therapy
- Improvement with cognitive processing therapy (CPT)
- Combined DBT and narrative exposure therapy (NET) improved symptoms of BPD and PTSD
- Trauma-informed NET therapy improved symptoms of BPD and PTSD
- Combined PE and EMDR improved symptoms of BPD in people with comorbid PTSD and BPD
Non-Trauma-Focused Treatments For PTSD
In patients with BPD and PTSD:
- The presence of BPD did not negatively impact outcomes for patients who participated in standard group therapy for PTSD, but neither patients with BPD nor PTSD showed symptom improvement after standard group therapy for PTSD
- Cognitive behavioral therapy (CBT) for PTSD showed improvement in patients with PTSD, but not BPD
- Brief CBT + Psychoeducation + Breath Training was associated with improvements in PTSD symptoms, but not BPD symptoms
Stage-Based Treatments for BPD-PTSD
In patients with BPD and PTSD:
- Dialectical behavior therapy + prolonged exposure (DBT + DBT PE) was associated with:
- Decreased suicidal ideation
- Decreased urge to commit suicide
- DBT + DBT PE was associated with:
- Decreases in PTSD symptoms, compared to DBT alone
- Decreases in suicide attempts
- Reduction in self-harm
- Greater full remission of PTSD symptoms, compared to DBT alone
- DBT + DBT PE was associated not associated with reduced BPD symptoms
- DBT + PTSD focused treatment was associated with:
- Reduction in PTSD symptoms
- Remission from PTSD symptoms
- Decreases in BPD symptoms
- Compared to CPT, DBT + PTSD focused treatment was associated with:
- Reduction in BPD symptoms
- Reduction in BPD-associated risky behavior, e.g. self-harm, substance use
- Reduction in PTSD symptoms
- Compared to DBT + PTSD focused treatment, adapted CPT was associated with:
- Faster time to remission
- Significant reduction of PTSD symptoms
- Moderate reduction of self-reported BPD symptoms
- Adapted CPT was not associated with clinician reported behavioral BPD symptoms
Those are the results, which indicate two things. First, patients with no recent history of suicidality, i.e. in the four months before treatment, trauma-informed therapy among patients with PTSD and BPD did not increase suicide risk. It’s important to understand that patients with suicidal behavior in the four months preceding treatment did not participate in treatment. For patients with co-occurring PTSD and BPD, more research is needed on reducing suicidality in patients with recent suicidal behavior. Second, stage-based treatments were the only approaches that led to reductions in both PTSD and BPD symptoms.
How This Research Helps Borderline Personality Disorder and Post-Traumatic Stress Disorder Treatment
One thing we learned is that there is still more research needed to improve our knowledge of how to support people with comorbid PTSD/BPD and recent suicidality: this research did not offer new data on how to best help this specific population. We’ll keep an eye on the research and report any new developments here.
With that said, this research did reveal something new and important: a step-wise approach, taken over time, can help patients with comorbid PTSD/BPD. The treatment we discuss above – DBT + PTSD focused therapy – showed effective reductions in the symptoms of both PTSD and BPD. What separates this approach from the others is the fact the treatment took place over the course of a full year, and patients only addressed PTSD symptoms after work with DBT led to emotional stabilization and preparation for exposure therapy. This is important: stability and distress tolerance in people with PTSD and BPD preceded exposure therapy. In addition, the presence of any self-harming behavior led to a pause in treatment until patients regained stability, as determined by clinicians.
That’s where this research teaches us the most: for patients with comorbid PTSD and BPD, data shows that safety and stability with DBT should precede work on trauma with exposure therapies, and that treatment that proceeds in this stepwise fashion can lead to positive outcomes and symptom reduction both PTSD and BPD.
Gianna Melendez
Jodie Dahl, CpHT