What treatment is recommended for a patient with Complex Post-Traumatic Stress Disorder (CPTSD), Borderline Personality Disorder (BPd), and Attention Deficit Hyperactivity Disorder (ADHD) who is already taking Vyvanse (lisdexamfetamine) 30mg?

Treatment Recommendation for CPTSD with Comorbid BPD and ADHD

Initiate trauma-focused psychotherapy immediately—specifically Dialectical Behavior Therapy for PTSD (DBT-PTSD)—without requiring a prolonged stabilization phase, as this addresses both CPTSD and BPD symptoms simultaneously while the patient continues Vyvanse for ADHD. 1

Primary Treatment: Trauma-Focused Psychotherapy

DBT-PTSD is the optimal choice for this specific combination of diagnoses, showing superior outcomes for patients with both BPD and PTSD compared to other interventions. 1

• DBT-PTSD demonstrated large effect sizes (d = 1.20) for PTSD symptoms and (d = 1.17) for BPD symptoms in patients with dual diagnosis of BPD + PTSD. 1
• This approach significantly outperformed cognitive processing therapy alone for both PTSD and BPD symptoms, as well as dissociation. 1
• Do not delay trauma-focused treatment by insisting on a prolonged stabilization phase—evidence shows patients with complex presentations, including BPD comorbidity, benefit from immediate trauma processing without adverse effects. 2

Alternative trauma-focused options if DBT-PTSD is unavailable include:

• Eye Movement Desensitization and Reprocessing (EMDR), which shows the strongest effect size (SMD -2.07) for PTSD symptom reduction. 3
• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), with sustained effects at follow-up. 3
• Schema-Focused Therapy, which demonstrated superiority over transference-focused therapy for BPD severity. 4

Pharmacotherapy Considerations

Continue Vyvanse 30mg for ADHD management, as psychostimulants may provide additional benefit for PTSD symptoms. 5

• A case report demonstrated that Vyvanse helped control intrusive thoughts and nightmares in a patient with comorbid ADHD and PTSD, potentially through dopaminergic mechanisms. 5
• The existing ADHD medication does not contraindicate trauma-focused psychotherapy and may actually support treatment. 5

If additional pharmacotherapy is needed for PTSD symptoms:

• Consider adding an SSRI (sertraline or paroxetine) if psychotherapy alone is insufficient or unavailable. 6
• For trauma-related nightmares specifically, prazosin starting at 1mg at bedtime is strongly recommended. 6, 7
• Absolutely avoid benzodiazepines—63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 6, 7

Critical Pitfalls to Avoid

Do not label this patient as "too complex" for standard trauma-focused treatment. 8, 7

• The assumption that affect dysregulation or BPD symptoms require extensive pre-treatment stabilization is not evidence-based. 2
• Delaying trauma-focused treatment communicates to patients that they are incapable of dealing with traumatic memories and reduces motivation for active trauma processing. 8
• Emotion dysregulation and impulsivity improve directly with trauma-focused treatment as the high sensitivity to trauma-related stimuli diminishes. 2, 6

Avoid psychological debriefing or crisis-focused interventions alone—these do not constitute adequate PTSD treatment and may be harmful. 2, 6

Treatment Sequencing Algorithm

1. Refer immediately to DBT-PTSD or EMDR/TF-CBT (whichever is available locally). 1, 3
2. Continue Vyvanse 30mg without interruption. 5
3. Monitor treatment response after 9-15 sessions—40-87% of patients no longer meet PTSD criteria after completing trauma-focused psychotherapy. 6, 7
4. Add SSRI only if psychotherapy is unavailable, ineffective after adequate trial, or patient strongly prefers medication augmentation. 6
5. Add prazosin if nightmares persist despite trauma-focused therapy. 6, 7

Expected Outcomes

• Both PTSD and BPD symptoms should significantly decrease with DBT-PTSD, with effect sizes exceeding 1.0 for both conditions. 1
• Psychotherapy provides more durable benefits than medication alone, with lower relapse rates after treatment completion. 6, 7
• The BPD diagnosis should not be viewed as requiring separate treatment—trauma-focused therapy addresses the underlying trauma that often drives BPD symptoms. 1, 9