The BPD-PTSD which to treatment first conundrum

In clinical practice being faced with co-morbidity is a common experience, and BPD-PTSD is one of these co-morbidities. The question of what to treat first or if co-morbidities should be treated concurrently was reviewed by a team out of Ryerson University, in Canada.

Richard Zeifman and his team (2021) completed a systematic review of psychotherapeutic approaches and treatment efficacy for comorbid borderline personality disorder and posttraumatic stress disorder. Here are some of their findings.

What did they examine?

Zeifman and his team examined 21 studies, reduced from an initial search that yielded 1610 studies in the area. They only examined adults and studies had to have BPD or subclinical BPD and PTSD or subclinical PTSD according to DSM-III-R, DSM-IV, or DSM-5.  They examined the safety considerations of treating BPD-PTSD; What happens when only one disorder is targeted and the impact of the stage-based approaches on both BPD and PTSD treatment outcomes.

Is providing trauma-focused treatment safe for individuals with BPD-PTSD?

Zeifman and colleuges reported that the studies they reviewed suggested that trauma-focused treatment does not lead to increased risk for suicide or self-harm in those with BPD-PTSD. However, (and an important however) they described that there was limitation to this statement because trauma-focused treatment was only implemented after a period of stabilization of suicidal or self-harm behaviours.

Does PTSD (or subclinical PTSD) hinder improvements in BPD-related outcomes associated with BPD-specific treatment.

Zeifman’s team examined six studies; findings were mixed. Most studies showed that PTSD symptoms such as suicidal ideation were not related to BPD outcomes or BPD severity. However, some studies did show negative outcomes. One reported less reduction in self-harm throughout treatment and another reported an increase in self-harm from post-treatment to follow up.

Do PTSD treatment reduce BPD symptoms?

Zeifman found three studies that examined the effectiveness of trauma focused treatment for reducing BPD-related outcomes in BPD-PTSD (or subclinical BPD-PTSD).

They reported that narrative exposure therapy (NET) or treatment by experts, which included elements of DBT and either outpatient psychiatric management or inpatient care were effective in reducing BPD symptoms.

Importantly these studies also reported that there no significant increases in urge to self-harm or suicide on days that included trauma-focused sessions or while completing the trauma-focused NET protocol.

The third study described by Zeifman and colleagues was an 8-day intensive trauma-focused treatment program, which included PE and EMDR. It showed significant pre-post decreases in BPD severity.

Do BPD treatments reduce PTSD symptoms?

Zeifman and colleagues identified four studies that examined the efficacy of BPD-specific treatment for reducing PTSD symptoms in BPD-PTSD

They reported most studies showed some improvement in PTSD symptoms when BPD was treated with DBT or community treatment by experts. However, the DBT treatment alone did not seem to have lasting effects. In contrast if the person was treated with DBT and DBT+PE the effects on PTSD appeared better and longer lasting.

Which is best to do first treat PTSD or BPD?

Unfortunately, the jury is still out on which is best to treat first. Zeifman and colleagues have reported trauma-focused treatment alone appears to lead to reductions in BPD symptoms among individuals with BPD-PTSD. Caution needs to be applied given that this is from a small number of studies, with limitations to the samples. In contrast, the staged based treatments focus on stabilisation of what could be considered prominent BPD features. More on this below.

Treatment that targets both BPD and PTSD; Staged based treatments.

Three stage-based treatments have been tested for BPD-PTSD. Stage-based treatment, in the BPD-PTSD context means that trauma-focused treatment is provided after:

1) safety concerns such as suicide attempts have ceased, and

2) skills to regulate or tolerate distressing emotions have been developed.

This staged based approach is different to the guidelines, for psychotherapy of complex PTSD released in 2012 by the International Society of Traumatic Stress Studies (ISTSS). These guidelines have since been contradicted.

Staged based treatments

The three stage-based treatments that have been tested for BPD-PTSD, they include:



EMDR plus stabilization-based sessions.

Zeifman and colleagues concluded that “The evidence base for stage-based treatments for BPD-PTSD is growing and suggests that they may be safe and efficacious in the treatment of PTSD, and at least some have documented efficacy for reducing BPD pathology as well.”


BPD-PTSD is a difficult area to treat, there is limited research. What research is present in regard to a specific approach for this co-morbidity appears to recommend stability in risk behaviours and regulation of affect before treating the PTSD. There is some effect on both co-morbidities if one of the comorbidities is treated. It is not clear how long lasting these effects might be.


Zeifman, R. J., Landy, M., Liebman, R. E., Fitzpatrick, S., & Monson, C. M. (2021). Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy. Clinical psychology review86, 102030.