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

Figures & data

Table 1. The studies exploring the efficacy of psychotherapy for PTSD in patients with personality disorders included in the meta-analyses (part A) and additional studies added in the review (part B).

Study	Design	N active arm	N control condition	Personality disorder	Intervention	Control	Treatment intensity	Outcome measure	Statistical significant	Dropout	Population and trauma
Part A
Bohus et al., 2013	RCT	17	16	BPD	DBT-PTSD	TAU WL	Group and individual, sessions totalling 7280 min	CAPS PDS	+ +	6% and 8% (with and without BPD)	Women – childhood sexual abuse and treatment-resistant PTSD
Harned et al., 2014	RCT	17	9	BPD	DBT+PE	DBT	Individual, mean 13 90-min sessions	PSS-I	+	25%	Women – (non)suicidal self-injurious behaviour, childhood abuse and other traumas
Kredlow et al., 2017 I	RCT	15	12	BPD	CBT	TAU	Individual, 12–16 50- mins essions	CAPS	+	14%	Women and men – childhood abuse and other traumas
Kredlow et al., 2017 II	RCT	29	26	BPD	CBT	BT	Individual, 12–16 50-min sessions	CAPS	-	26% and 13%	Women and men – childhood abuse and other traumas Severe PTSD CAPS ≥65
Feeny et al., 2002	RCT	9	-	BPC	PE, SIT, or PE + SIT	-	Individual, 9 sessions mean 97 min	PSS-I	+	25%	Women – sexual and nonsexual assault Chronic PTSD
Walter et al., 2012	Open	110	-	Personality disorders	CPT	-	12 sessions of 90-min group CPT, 13 individual sessions 50–60 min	CAPS PCL	+ +	7% (with and without PD)	Female and male patients – combat, childhood sexual abuse and other traumas
Harned et al., 2012	Open	13	-	BPD	DBT+PE	-	Individual 90 min, mean 13 sessions Plus DBT	PSS-I	+	23%	Women – (non)suicidal self-injurious behaviour, childhood abuse and other traumas
Pabst et al., 2014	CT	11	11	BPD	NET	TBE	Individual, 17 to 90 min	PDS	-	18%	Women – physical and sexual abuse
Steuwe et al., 2016	Open	11	-	BPD	NET	-	Individual, 15 sessions mean 97 min	PDS	+	9%	Female and male patients – childhood abuse and other traumas
Holder et al., 2017	RCT	7	-	BPD	CPT	-	Individual, 12 sessions, minutes NA	CAPS PCL	+ +	29%	Women – military sexual trauma, only patients randomized for CPT were included
Meyers et al., 2017	Open	14	-	BPD	DBT + PE	-	Group and individual, sessions NA, min NA	PCL	+	29%	Female and male patients – veterans Data available for 14 patients
Slotema et al.,	Open	47	-	Personality disorders	EMDR	-	Individual, median 4 sessions, mean 75 min	PDS	+	32%	Female and male patients – 82% childhood trauma and other traumas
Steil et al., 2018	Open	21	-	≥ 4 BPD criteria, 75% BPD	DBT-PTSD	-	Group and individual, up to 40 hours	CAPS DTS	+ +	19%	Women – childhood sexual abuse
De Jongh et al., 2020	Open	35	-	Borderline symptom List ≥2	PE + EMDR Physical exercise, psycho-education	-	Individual 1440 minutes	CAPS PCL	+ +	0	Woman and men with childhood abuse and other traumas
Part B
Cloitre & Koenen, 2001	CT	5	6	BPD	Interpersonal process group therapy	WL	Group, 12 sessions, 90 min	PSS	-	NA	Data not sufficient for meta-analysis Women – childhood sexual abuse
Hembree et al., 2004	RCT	29	-	Personality disorders	PE or PE/CR	-	Individual, number of sessions NA, 105 min	PSS-I Prevalence of PTSD	NA +	NA	Prevalence of PTSD outcome measure Data not sufficient for meta-analysis Women – rape or nonsexual assault in adulthood or sexual abuse in childhood, chronic PTSD
Clarke et al., 2008	RCT	39	-	BPD	CBT	-	Individual, 9 sessions, mean 87 min	CAPS	+	36% with and without PD	Data not sufficient for meta-analysis Female rape victims

BPC = borderline personality characteristics, BPD = borderline personality disorder, BT = brief treatment (involving breathing training and psycho-education about trauma and PTSD), CAPS = Clinician-Administered PTSD Scale, CBT = cognitive-behavioural therapy, CPT = cognitive-processing therapy, CT = controlled trial, DBT = dialectical behavioural therapy, DTS = Davidson Trauma Scale, EMDR = eye movement desensitization and reprocessing, NA = not applicable, NET = narrative exposure therapy, PCL = Posttraumatic stress disorders CheckList, PD = personality disorder, PDS = Posttraumatic Stress Diagnostic Scale, PE = prolonged exposure, PE/CR = prolonged exposure and cognitive restructuring, PSS = Posttraumatic Stress Symptom Scale, PSS-I = Posttraumatic Stress Symptom Scale – Interview, PTSD = posttraumatic stress disorder, RCT = randomized-controlled trial, SIT = stress inoculation training, TAU = treatment as usual, TBE = treatment by experts (for borderline personality disorder), WL = waiting list.

Figure 1. Flowchart of studies exploring the effects of psychotherapy of posttraumatic stress disorder (PTSD) in patients with personally disorders.

Table 2. Quality of studies exploring PTSD-focused psychotherapy in patients with personality disorders included in the meta-analyses.

Study	Structured clinical interview for PTSD	Randomization	Blind data assessment	Drop out	Tolerability	Post-treatment and follow-up assessments included	Intention-to-treat analysis
Bohus et al., 2013	+	+	+	+	+	+	+
Harned et al., 2014	+	+	+	+	+	+	+
Kredlow et al., 2017 I	+	+	+	+	+	+	+
Kredlow et al., 2017 II	+	+	+	+	+	+	+
Feeny et al., 2002	+	+	+	+	-	+	-
Walter et al., 2012	-	-	-	+	-	-	-
Harned et al., 2012	+	-	+	+	+	+	+
Pabst et al., 2014	+	-	+	+	-	-	+
Steuwe et al., 2016	-	-	+	+	+	+	+
Holder et al., 2017	+	+	+	+	-	+	-
Meyers et al., 2017	+	-	Self-reports	+	+	-	-
Slotema et al.,	-	-	Self-reports	+	+	-	+
Steil et al., 2018	+	-	-	+	+	+	+
De Jongh et al., 2020	+	-	-	+	+	-	-

PTSD = posttraumatic stress disorder.

Table 3. Results on the heterogeneity and publication bias for the studies included in the meta-analyses.

	Q	p	df	I^2	Fail-safe number
PTSD RCTs	2.56	0.47	3	0	56
PTSD all studies	47.24	<.001	13	72.48	3,279
Depression RCTs	12.90	0.005	3	76.74	14
Depression all studies	22.34	0.004	8	64.18	436
Anxiety RCTs	0.79	0.67	2	0	0
Anxiety all studies	6.93	0.14	4	42.32	52
Borderline symptoms RCTs	4.15	0.13	2	51.82	6
Borderline symptoms all studies	15.73	0.015	6	61.86	142
PTSD patients BPD RCTs	2.56	0.47	3	0	56
PTSD patients BPD all studies	37.32	<.001	12	67.85	2,188
PTSD after 3 months RCTs	6.11	0.11	3	50.91	57
PTSD after 3 months all	20.73	0.008	8	61.40	629

BPD = borderline personality disorder, PTSD = posttraumatic stress disorder, RCTs = randomized-controlled trials.

Table 4. Results of the meta-analyses of studies exploring PTSD-focused psychotherapy in patients with personality disorders.

	Studies n	Sample size n	Hedges’ g	Z	p
PTSD RCTs	4	141	0.54	3.17	0.002
PTSD all studies	14	430	1.04	6.75	<.001
Depression RCTs	4	141	0.64	1.72	0.0085
Depression all studies	9	217	0.73	3.85	<.001
Anxiety RCTs	3	108	0.17	0.89	0.37
Anxiety all studies	5	130	0.48	2.48	0.013
Borderline symptoms RCTs	3	115	0.43	1.56	0.12
Borderline symptoms all studies	7	204	0.52	2.87	0.004
PTSD patients BPD RCTs	4	141	0.54	3.17	0.002
PTSD patients BPD all studies	13	295	1.04	5.94	<.001
PTSD after 3 months RCTs	4	141	0.82	3.19	0.001
PTSD after 3 months all	9	203	0.98	4.61	<.001

BPD = borderline personality disorder, PTSD = posttraumatic stress disorder, RCT = randomized-controlled trial.

Figure 2. Meta-analysis of the four randomized-controlled trials evaluating PTSD symptom severity after trauma-focused psychotherapy in patients with personality disorders.

Figure 3. Meta-analysis of all studies exploring the effects of psychotherapy for posttraumatic stress disorder (PTSD) on the severity of PTSD in patients with personality disorders.

Figure 4. Meta-analysis of all studies exploring the efficacy of psychotherapy for posttraumatic stress disorder on the severity of depression in patients with personality disorders.

Figure 5. Meta-analysis of all studies exploring psychotherapy for posttraumatic stress disorder on severity of anxiety in patients with personality disorders.

Figure 6. Meta-analysis of all studies exploring psychotherapy for posttraumatic stress disorder on severity of borderline symptoms in patients with personality disorders.

Figure 7. Meta-analysis of all studies exploring psychotherapy for posttraumatic stress disorder (PTSD) on severity of PTSD patients with borderline personality disorder.

Figure 8. Meta-analysis of all studies exploring psychotherapy for posttraumatic stress disorder (PTSD) on severity of PTSD patients after at least three months of follow-up in patients with personality disorders.

Bohus, M., Dyer, A. S., Priebe, K., Krüger, A., Kleindienst, N., Schmahl, C., … Steil, R. (2013). Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: A randomised controlled trial. Psychotherapy and Psychosomatics, 82(4), 221–233.

 PubMed Web of Science ®Google Scholar

Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7–17.

 PubMed Web of Science ®Google Scholar

Kredlow, M. A., Szuhany, K. L., Lo, S., Xie, H., Gottlieb, J. D., Rosenberg, S. D., & Mueser, K. T. (2017). Cognitive behavioral therapy for posttraumatic stress disorder in individuals with severe mental illness and borderline personality disorder. Psychiatry Research, 249, 86–93.

 Web of Science ®Google Scholar

Feeny, N. C., Zoellner, L. A., & Foa, E. B. (2002). Treatment outcome for chronic PTSD among female assault victims with borderline personality characteristics: A preliminary examination. Journal of Personality Disorders, 16(1), 30–40.

 Web of Science ®Google Scholar

Walter, K. H., Bolte, T. A., Owens, G. P., & Chard, K. M. (2012). The impact of personality disorders on treatment outcome for veterans in posttraumatic stress disorder residential treatment program. Cognitive Therapy and Research, 36(5), 576–584.

 Web of Science ®Google Scholar

Harned, M. S., Korslund, K. E., Foa, E. B., & Linehan, M. M. (2012). Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a dialectical behavior therapy prolonged exposure protocol. Behaviour Research and Therapy, 50(6), 381–386.

 PubMed Web of Science ®Google Scholar

Pabst, A., Schauer, M., Bernhardt, K., Ruf-Leuschner, M., Goder, R., Elbert, T., & Seeck-Hirschner, M. (2014). Evaluation of narrative exposure therapy (NET) for borderline personality disorder with comorbid posttraumatic stress disorder. Clinical Neuropsychiatry, 11, 108–117.

 Google Scholar

Steuwe, C., Rullkötter, N., Ertl, V., Berg, M., Neuner, F., Beblo, T., & Driessen, M. (2016). Effectiveness and feasilibility of narrative exposure therapy (NET) in patients with borderline personality disorder and posttraumatic stress disorder – A pilot study. BMC Psychiatry, 16(1), 254.

 PubMedGoogle Scholar

Holder, N., Holliday, R., Pai, A., & Surís, A. (2017). Role of borderline personality disorder in the treatment of military sexual trauma-related posttraumatic stress disorder with cognitive processing therapy. Behavioural Medicine, 43(3), 184–190.

 PubMed Web of Science ®Google Scholar

Meyers, L., Voller, E. K., McCallum, E. B., Thuras, P., Shallcross, S., Velasquez, T., & Meis, L. (2017). Treating veterans with PTSD and borderline personality symptoms in a 12-week intensive outpatient setting: Findings from a pilot program. Journal of Traumatic Stress, 30(2), 178–181.

 PubMed Web of Science ®Google Scholar

Steil, R., Dittmann, C., Müller-Engelmann, M., Dyer, A., Maasch, A. M., & Priebe, K. (2018). Dialectical behaviour therapy for posttraumatic stress disorder related to childhood sexual abuse: A pilot study in an outpatient treatment setting. European Journal of Psychotraumatology, 9(1), 1423832.

 PubMed Web of Science ®Google Scholar

De Jongh, A., Groenland, G. N., Sanches, S., Bongaerts, H., Voorendonk, E. M., & van Minnen, A. (2020). The impact of brief intensive trauma-focused treatment for PTSD on symptoms of borderline personality disorder. European Journal of Psychotraumatology, 11(1), 1721142.

 PubMed Web of Science ®Google Scholar

Cloitre, M., & Koenen, K. C. (2001). The impact of borderline personality disorder on process group outcome among women with posttraumatic stress disorder related to childhood abuse. International Journal of Group Psychotherapy, 51(3), 379–398.

 PubMed Web of Science ®Google Scholar

Hembree, E. A., Cahill, S. P., & Foa, E. B. (2004). Impact of personality disorders on treatment outcome for female assault survivors with chronic posttraumatic stress disorder. Journal of Personality Disorders, 18(1), 117–127.

 Web of Science ®Google Scholar

Clarke, S. B., Rizvi, S. L., & Resick, P. A. (2008). Borderline personality characteristics and treatment outcome in cognitive-behavioral treatments for PTSD in female rape victims. Behavioral Therapy, 39(1), 72–78.

 PubMed Web of Science ®Google Scholar