Exposure therapy and Borderline Personality Disorder

Ulrich:

Just a quick comment in follow-up to the discussion of Cloitre et al. (2002):

The inclusion/exclusion criteria for this study were, "Inclusion criteria required the presence of DSM-IV-defined diagnosis of PTSD related to childhood sexual abuse, physical abuse, or both...Exclusion criteria included current diagnosis of organic or psychotic mental disorders, substance dependence, eating disorder, dissciative disorder, Bipolar I disorder or *borderline personality disorder*" (p. 1068, emphasis added)

My colleagues (Feeny, Zoellner, & Foa, 2002) recently conducted a reanalysis of data collected in the Foa et al. (1999) outcome study comparing prolonged exposure (PE), stress inoculation training (SIT), combination treatment (PE/SIT) and waitlist (WL). Subjects were women with PTSD resulting from a physical or sexual assault occurring after age 16. Although the study ruled out child abuse occuring before age 16, the study did not rule out borderline personality disorder (BPD) per se (it did rule out people for active suicidal ideation or active parasuicidal behavior). They report outcome data for 9 women who met critiera for full (meets at least 5 criterion for BPD as required by DSM) or "partial" (meets 3 or 4 criterion) and 48 women who did not meet criteria for full or partial BPD.

Despite the presence of BPD or at least borderline traits, there were no statistically significant differences between the groups on the individual outcome measures. It is true that numerically speaking, the BDP/partial PBD group had numerically higher scores and the non-significacne could be due to low power. Also, when you combined measures into a measure of good end-state functioning, you clearly saw that the BPD was not doing as well as the Non-BPD.

However, the important point is that the PBC patients did show significant improvement event when treatment was focussed on PTSD, and without the "benefit" of extensive pretreatment with DBT. For example, in the Non-BPD group, the PSS-I went from 30 to 11, in the BPD group it went from 29 to 19. On the BDI, the Non-BPD group went from 19 to 8, the BPD group went from 27 to 13.

Now, this sample didn't include childhood abuse victims, and the cases of BPD clearly weren't the most difficult cases that present for treatment (i.e., those actively engaged in parasuicidal behavior), but they begin to close the gap a bit, and raise the possibility that perhaps prior treatment with DBT isn't necessary. It may still be helpful, but we won't know one way or the other until someone does the study.

This little study definitely is not the final word, but it is a step in the right direction. Also, the study we've recently completed included a significant minority of subjects with childhood sexual abuse as the index trauma. We will be able to investigate whether CSA survivors had any worse outcome than other types of assault.

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 examiniation. Journal of Personality Disorders, 16, 30-40.

Replies:

Re:Exposure therapy and Borderline Personality Disorder, by Ulrich Lanius, Ph.D., 02/12/03 Re:Exposure therapy and Borderline Personality Disorder, by Cahill, 02/12/03 One more thing for Ulrich, by Cahill, 02/12/03

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