As any clinician would know Personality Disorder also means complexity and many cavets can apply during therapy. So too complexity applies to the research on comorbid PD and PTSD.
Before discussing the review of the impact of comorbid personality disorders on psychotherapy for PTSD by Aishah Snoek and team (2021) it is important to acknowledge the potential challenges in this area.
This meta analysis and review only had a small number of included studies (N = 12). The studies were heterogeneous regarding age, trauma history, treatment type and duration, most participants (approx. 72%) were female. The majority of the studies were of BPD. Although other PD were included, such as paranoid, avoidant, narcissistic, dependent, obsessive– compulsive, passive- aggressive, antisocial, and schizotypal these were not studied individually. Similarly, the assessment of PD in some studies was by self-assessment. Which may have the potential to over or under inflate numbers.
The authors warned that there were only three studies that had a low risk of bias. That said, what were the findings?
The findings
Of the 12 studies reporting on 918 patients in this review the authors found that:
Patients with comorbid personality disorders (all types)
- Did not have significantly higher baseline PTSD severity
- Were not at higher risk for dropout from PTSD treatment
- Still benefited from PTSD treatment (although not as much as those without PD)
Because there were so many studies of BPD the authors also examined this group.
Borderline PD
No statistically significant difference was found between patients with and without comorbid borderline PD in:
- Pre-treatment PTSD severity
- Dropout from PTSD treatment
- Pre- to posttreatment improvement in PTSD symptoms
- The number of treatment responders
A statistically significant large effect size of the pre- to post-treatment improvement in PTSD scores was found in patients with comorbid Borderline Personality Disorder (Hedges’ g = 1.45, 95%CI 0.71–2.18, p = .004).
Aishah Snoek, and team (2021) concluded, that their meta-analysis suggested that although the presence of comorbid PDs does not preclude a good response to PTSD treatment, patients with comorbid PDs might have less gains from PTSD treatment than those who do not have a PD.
More on Borderline Personality
Christina Slotema and team’s (2020) systematic review and meta-analysis of psychotherapy for PTSD in patients with borderline personality disorder concluded that psychotherapy for PTSD is efficacious and safe for patients with borderline personality disorder and should not be withheld from these vulnerable individuals.
They described that four RCTs showed a significant, moderate to high standardized effect size for reducing PTSD symptom severity with effects being maintained at least 3 months. Similarly, they reported, across all the studies they examined (some were not RCT’s) there was
- a significant decrease in symptoms of depression, anxiety, borderline symptoms.
- No increase in self-injurious behaviour,
- No suicide attempts
- No hospitalization
- The average dropout rate during PTSD treatment was 17%.
They concluded that psychotherapy for PTSD is efficacious and safe for patients with borderline personality disorder and should not be withheld from these vulnerable individuals.
Summary
The presence of a PDs may inhibit a good response for some with co-morbid PD and PTSD. Such as paranoid, avoidant, narcissistic, dependent, obsessive– compulsive, passive- aggressive, antisocial, and schizotypal personality disorders. However, if the PD is Borderline Personality Disorder treating the PTSD does not preclude a good response to PTSD treatment.
As common sense suggests not all personality disorders are the same. However, the most common (highest prevalence) disorder is not a complete barrier to PTSD treatment.
References
Slotema, C. W., Wilhelmus, B., Arends, L. R., & Franken, I. H. A. (2020). Psychotherapy for posttraumatic stress disorder in patients with borderline personality disorder: A systematic review and meta-analysis of its efficacy and safety. European Journal of Psychotraumatology, 11(1), 1796188. https://doi.org/10.1080/20008198.2020.1796188
Snoek, A., Nederstigt, J., Ciharova, M., Sijbrandij, M., Lok, A., Cuijpers, P., & Thomaes, K. (2021). Impact of comorbid personality disorders on psychotherapy for post-traumatic stress disorder: Systematic review and meta-analysis. European Journal of Psychotraumatology, 12(1), 1929753. https://doi.org/10.1080/20008198.2021.1929753
