Narrative exposure therapy can be used with BPD patients in a standard clinical setting

An investigation published in the current issue of Psychotherapy and Psychosomatics introduces a new treatment for borderline personality disorder (BPD) that ensues after a traumatic stress.

The present study demonstrates that narrative exposure therapy (NET) can within weeks achieve a marked improvement in borderline patients with comorbid PTSD, even under the often less than ideal conditions in a psychiatric ward. NET can be used with borderline patients in a standard clinical setting (out- and inpatient).

Whereas BPD is already characterized by a high rate of psychiatric problems, current evaluations indicate that the frequency of comorbid posttraumatic stress disorder (PTSD) ranges between 33 and 61% among patients with BPD. When there is comorbid PTSD, BPD symptoms are potentially intensified by the related anxiety, hyperarousal and intrusions, triggering sudden, uncontrollable and incomprehensible attacks of tension and fear. This prompts a vicious circle of uncontrollable swings in tension and dysfunctional behavioral patterns (e.g. self-inflicted pain and injuries), which in turn makes it impossible to modify maladaptive core beliefs. The present approach sought to test the feasibility of narrative exposure therapy (NET), a trauma-focused therapy suitable for both in- and outpatient settings which can be taught to clinically experienced therapists in a short-term training program and implemented in a comprehensive treatment for BPD patients with comorbid PTSD. Within an open trial, 10 women with BPD and comorbid PTSD were treated at the Center of Integrative Psychiatry in Kiel using NET. NET is a standardized, controlled short-term intervention which is based on the core assumption that a maladaptive trauma related network of memory representations has resulted from multiple adverse and fearful experiences. NET is now considered to be a comparatively well-tested therapy approach for patients who have survived different types of trauma, ranging from domestic violence and emotional neglect to organized violence. It aims primarily at reducing PTSD symptoms by changing associative memory related to the traumatic experiences through recall of the event and exposure, assigning each event the respective time and place at which it had been experienced. This promotes a coherent autobiographical memory associated with the sensory, affective and cognitive cues of the event, and in addition has non dissociative effects. During the period between January 2009 and May 2010, 12 women presenting with BPD and comorbid PTSD were recruited from a clinic. Prior to treatment, a diagnosis was reached by conducting a standardized and structured clinical interview based on the Mini-International Neuropsychiatric Interview and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. After the initial diagnosis, the Posttraumatic Stress Diagnostic Scale (PDS) was applied as an interview. This instrument records PTSD symptoms in accordance with the DSM-IV. Depression symptoms were assessed by clinician ratings using the Hamilton Depression Rating Scale (HAM-D), as well as by means of the Hopkins Symptom Checklist 25 (HSCL- 25). The severity of BPD symptoms was evaluated by self- assessment with the aid of a short version of the Borderline Symptom List 23 (BSL-23), and dissociative symptoms were recorded by means of the Fragebogen zu dissoziativen Symptomen (FDS).

Overall, it was possible to carry out NET for all patients. On average, 14 NET sessions (range: 11-19 sessions) were necessary, taking into account that the number of sessions depends on the amount and severity of traumatic events. Based on Wilcoxon tests, there was a significant reduction in symptoms of PTSD (p<0.05) as assessed by the PDS, depression (p<0.05) as assessed using the HAM-D, and dissociation as assessed by the FDS (p<0.05). With respect to BPD symptoms, recorded using the BSL-23, the noted drop would become significant if an α level of 0.10 were used. So far, the present study has demonstrated the feasibility of NET, in that a team of clinicians (psychologists and psychiatrists) who has received a 2-day training in NET, as well as subsequent group supervision, can within weeks achieve a marked improvement in borderline patients with comorbid PTSD using NET as a treatment module, even under the often less than ideal conditions in a psychiatric ward. Thus, the findings of this study demonstrate that NET can be used with borderline patients in a standard clinical setting (out- and inpatient).