What is the treatment approach for borderline personality disorder versus complex post-traumatic stress disorder (PTSD)?

From the Guidelines

The treatment approaches for borderline personality disorder (BPD) and complex post-traumatic stress disorder (CPTSD) differ in focus but share some overlapping elements, with dialectical behavior therapy (DBT) being the gold standard for BPD and a phase-based approach emphasizing safety and stabilization before trauma processing being commonly used for CPTSD, as supported by recent studies 1.

Key Differences in Treatment Approaches

• For BPD, the primary focus is on emotional regulation, interpersonal effectiveness, and reducing self-destructive behaviors, with DBT typically delivered over 6-12 months with weekly individual therapy, group skills training, phone coaching, and therapist consultation teams.
• For CPTSD, treatment emphasizes processing traumatic memories and rebuilding a sense of safety after chronic trauma exposure, with trauma-focused cognitive behavioral therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), and sensorimotor psychotherapy being commonly used.

Medication Use in BPD and CPTSD

• Medications for BPD are used symptomatically rather than as primary treatment, with mood stabilizers like lamotrigine (100-200mg daily) or topiramate (50-200mg daily) helping with emotional instability, and atypical antipsychotics such as aripiprazole (2-15mg daily) or olanzapine (2.5-10mg daily) addressing impulsivity and anger.
• Medication for CPTSD often includes SSRIs like sertraline (50-200mg daily) or fluoxetine (20-80mg daily) for core symptoms, with prazosin (1-15mg at bedtime) sometimes added for nightmares.

Recent Studies and Recommendations

• Recent studies 1 suggest that the evidence does not currently support the recommendation for a stabilization phase prior to providing trauma-focused treatment in persons with CPTSD, and that trauma-focused therapies can be effective in many PTSD patients with complex presentations.
• The current ISTSS Guidelines provide an incomplete view of the extant literature, and it is recommended that trauma-focused therapies should routinely be offered to individuals with complex presentations of PTSD in an adequate dose, consistent with current general PTSD treatment guidelines 1.

From the Research

Treatment Approaches for Borderline Personality Disorder (BPD) and Complex Post-Traumatic Stress Disorder (PTSD)

• The treatment of BPD and complex PTSD can be challenging due to the complexity of the disorders and their high comorbidity rates 2.
• Studies have shown that psychotherapy is the treatment of choice for BPD, with various approaches such as dialectical behavior therapy (DBT), mentalization-based therapy, transference-focused therapy, and schema therapy being empirically supported 3.
• DBT has been found to be effective in reducing PTSD symptom severity and comorbid depressive symptoms in individuals with BPD and PTSD 4, 5.
• A randomized clinical trial found that DBT-PTSD was more effective than cognitive processing therapy (CPT) in reducing PTSD and BPD symptoms in individuals with a dual diagnosis of BPD and PTSD 5.
• The implementation of DBT in public health systems has been found to be effective in reducing symptoms of BPD, but ongoing research and evaluation are recommended to address implementation challenges 6.

Key Considerations for Treatment

• The treatment of BPD and complex PTSD requires a comprehensive approach that addresses the full spectrum of core symptoms 2, 5.
• The choice of treatment approach may depend on the individual's specific needs and circumstances, and a thorough assessment is necessary to determine the most effective treatment plan 3.
• The use of stage-based treatments, such as DBT-PTSD, may be effective in reducing symptoms of PTSD and BPD in individuals with a dual diagnosis 4, 5.
• Further research is needed to address the gaps in the literature and to provide more effective treatments for individuals with BPD and complex PTSD 2, 3, 4, 5, 6.