CPT Group for DBT Clients With Co-Occurring Borderline Personality Disorder and PTSD
Condition: Borderline Personality Disorder; Posttraumatic Stress Disorder
MeSH terms: Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic; Personality Disorders; Borderline Personality Disorder
Study type: Interventional

Summary: 
      Even though borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD)
      commonly co-occur, few studies have examined PTSD treatment among individuals with BPD.
      Additionally, many PTSD research studies exclude individuals with BPD due to their complexity
      and concerns regarding risk. This study aims to investigate the effectiveness of
      Cognitive-Processing Therapy Group (an evidenced-based treatment for PTSD) for individuals
      with these co-occurring disorders following completion of a Dialectical Behavioural Therapy
      Program (an evidenced-based treatment for BPD). The investigators are using a repeated
      measures pre and post design. Data will be collected prior to participants starting the CPT
      group, throughout the duration of the CPT group (i.e., weekly), and following the completion
      of the CPT group.
    

Detailed description: 
      Borderline personality disorder (BPD) is a severe psychological disorder characterized by
      instability in emotion regulation, interpersonal relationships, and self-image, coupled with
      marked impulsivity. Additionally, individuals with BPD often meet criteria for other
      disorders. One of the most commonly co-occurring disorders among individuals diagnosed with
      BPD is posttraumatic stress disorder (PTSD). Within this population, 56% to 58% of
      inpatients, and between 36% to 50% of outpatients are diagnosed with co-occurring PTSD.

      The high prevalence of this co-occurrence is consistent with studies documenting the severe
      traumatic experiences (including, but not limited to, physical, sexual, and emotional abuse,
      both as children and adults) commonly experienced by individuals diagnosed with BPD .
      Additionally, risk factors for PTSD identified by meta-analyses share striking commonalities
      with those of BPD, including: lack of social support, prior history of trauma (including
      childhood abuse), and poor psychological adjustment prior to trauma.

      The co-occurrence of BPD/PTSD is associated with poorer outcomes and significant distress
      than the presence of either disorder alone. For example, individuals with co-occurring
      BPD/PTSD exhibit a lower likelihood of remission from BPD after 10 years of follow-up, and
      are also more likely to engage in non-suicidal self-injurious behavior (NSSI). In addition,
      BPD patients diagnosed with PTSD are also faced with greater emotional dysfunction and global
      psychological distress, as well as inferior physical health compared to individuals with BPD
      alone.

      Several studies have proposed theories on the high co-occurrence of these disorders, but few
      have investigated potential treatments to address the unique issues associated with this
      comorbidity. The current standard of treatment for BPD, Dialectical Behaviour Therapy (DBT),
      has a solid empirical basis, including numerous randomized control trials (RCTs)
      demonstrating its efficacy in the reduction of associated symptoms. Despite the efficacy of
      DBT, the DBT treatment manual (Linehan, 1993) did not outline a specific protocol for
      intervention in patients with co-occurring BPD and PTSD. Moreover, outcomes from DBT trials
      indicate that DBT alone does not adequately treat co-occurring BPD/PTSD. Specifically, data
      from an RCT evaluating DBT in suicidal women with BPD demonstrated that only 13% of patients
      diagnosed with BPD/PTSD achieved full remission from PTSD during one year of DBT.

      Recently, researchers have focused on identifying how to treat individuals with BPD and PTSD
      within the context of DBT. Harned and colleagues have developed and tested a combined DBT PE
      protocol that has shown efficacy in treating BPD/PTSD. This combined treatment addresses some
      of the problems inherent in the direct application of the conventional PTSD treatment,
      prolonged exposure (PE) therapy for individuals with BPD. Evaluations of PE show that PE
      significantly reduces PTSD symptoms and secondary outcomes such as depression. PE is designed
      to counteract avoidance of traumatic memories through repeated exposure to the traumatic
      memory, as well as in vivo exposure to non-dangerous events perceived to be fearful by the
      patient. The intention of the treatment is to alleviate overestimation of the likelihood and
      severity of negative outcomes, as well as conditioned fear responses to certain situations,
      often experienced by PTSD patients.

      Several characteristics of individuals with BPD interfere with the ability to engage in
      emotional exposure, the central intervention of PE therapy. These may include: self-injurious
      behaviours, other co-occurring issues (e.g. dissociation, substance use, ongoing trauma),
      emotional dysregulation (over-engagement, under-engagement, and strong non-fear emotions),
      trauma memory characteristics (large quantity and/or poor quality of trauma memories), and
      treatment noncompliance. The combined DBT protocol includes specific strategies to address
      these problems. While this combined DBT/PE protocol is an important step towards addressing
      the gap in treatment for individuals with co-occurring BPD/PTSD, there are other
      evidenced-based interventions that also merit evaluation in a combined DBT/PTSD treatment,
      notably Cognitive Processing Therapy (CPT).

      Like PE, CPT has a strong evidence base to support its effectiveness treating PTSD. The
      protocol for CPT was initially generated as a treatment for victims of sexual assault and has
      since been successfully used to treat other types of trauma . It consists of cognitive
      therapy focused on how the traumatic event has impacted the individual's beliefs about
      themselves, others, and the world in general. The treatment involves 12 sessions of therapy,
      along with homework between sessions. The objective of the treatment is to first help
      patients identify dysfunctional beliefs and assumptions stemming from the traumatic
      experiences, challenge these beliefs (i.e., "stuck points", and then develop new beliefs
      reflecting a broader perspective.

      While combined DBT/PE treatment is encouraging, CPT may have benefits that are similar to, if
      not superior to PE in some ways. Research on CPT indicates that treatment is similarly
      effective to PE in reducing PTSD symptoms and depression. However, their respective impact on
      secondary symptoms may differ due to the different mechanisms underlying each treatment. For
      example, one study suggested that CPT may be superior to PE on specific scales of guilt. One
      distinct benefit of CPT is that it is available and efficacious in both individual and group
      formats, whereas PE is available only individually. Group CPT allows efficient use of
      resources, which is critical in the context of a publicly funded health-system. In light of
      the fact that Standard DBT requires extensive clinician resources, the efficient use of
      supplementary treatments is even more critical. Finally, there may be other benefits to group
      that warrant research, including reduction of stigma of PTSD and associated shame by
      addressing this within a group context.

      This study aims to assess the efficacy of CPT to address PTSD symptoms among individuals with
      co-occurring BPD/PTSD who are participating in Standard DBT. It is hypothesized that
      individuals will show significant reductions in primary symptom outcomes (PTSD) and secondary
      symptom outcomes (e.g., BPD symptoms, shame, anxiety, depression) between pre and post-
      treatment. This study aims to provide one of the first clinical examinations of the
      effectiveness of CPT as a treatment for co-occurring BPD and PTSD among individuals
      participating in Standard DBT. The results of such a trial could not only lead to the
      establishment a potentially clinically effective and cost-effective alternative to PE in this
      population, but also further elucidate the mechanism behind this complex comorbidity.
    

Intervention name(s): Cognitive Processing Therapy
Intervention type(s): Behavioral
Intervention description(s): Cognitive Processing Therapy is an evidenced-based treatment for PTSD. The investigators are offering CPT group over 13 weeks (12 group sessions & 1 individual session). CPT focuses on challenging beliefs that developed or were reinforced following the trauma(s).
Other intervention name(s): CPT
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Borderline Personality Disorder; Posttraumatic Stress Disorder; Cognitive Processing Therapy; Group Therapy; Comorbidity; Dialectical Behavior Therapy