Treating PTSD in patients suffering from Borderline Personality Disorder with EMDR

People suffering from psychological trauma often experience cognitive,
behavioral and physiological effects. Eye movement desensitization and
reprocessing (EMDR) therapy (Shapiro, 1989) uses both cognitive and affective
processing in treating trauma (Solomon & Heide 2005) and is effective in the
treatment of (chronic) posttraumatic stress disorder (PTSD) (Bisson, Roberts,
Andrew, Cooper & Lewis, 2013). According to the Dutch multidisciplinary
guideline for anxiety disorders both cognitive-behavioral therapy (CBT) and
EMDR are the treatments of choice for patients suffering from PTSD (Van Balkom
e.a., 2013).

Borderline personality disorder (BPD) is a diagnosis that deeply impairs
peoples* lives and has a high rate of comorbidity with several disorders (Brown
& Shapiro 2006). The presence of PTSD in patients with BPD has been researched
extensively. In a review investigating comorbidity between the two it is
concluded that between 33% and 79% of patients diagnosed with PTSD or BPD have
comorbidity with the other (Frias & Palma 2015). The nosology of this
comorbidity, however, remains unclear. It has even been suggested that BPD may
be a type of *chronic PTSD* (ten Broeke, de Jongh & Oppenheim, 2008).

In spite of this unclarity, research shows that BPD-PTSD patients have more
severe symptoms, such as emotional dysregulation and suicidal tendencies than
BPD patients without PTSD. Preliminary evidence suggests that it is effective
to treat both pathologies, which is why Frias & Palma (2015) stress the need
for further research on treating both PTSD ánd BPD in BPD/PTSD patients.
BPD is, according to current standards, best treated with specialized
treatments such as Dialectical Behavior Therapy (DBT) (van den Bosch e.a.,
2002) or Schema Focused Therapy (SFT) (Giesen-Bloo e.a., 2006).

The aforementioned guideline for treating PTSD however is not usually applied
when patients suffer from both PTSD and BPD, since trauma therapy (e.g.
prolonged exposure) is thought to be counterproductive in a BPD population with
suicidal tendencies. There is, according to some, a risk that BPD patients
might have less abilities to cope with the intrapsychic dynamics that result
from trauma therapy and be at a substantial risk of revictimization (Foa,
Hembree & Rothbaum, 2007; Frias & Palma, 2015). There is however, no conclusive
evidence supporting this idea (van Minnen, Harned, Zoellner & Mills, 2013),
although people remain hesitant to treat PTSD in PTSD/BPD patients with acute
suicidality.

Ford et al. (2005) describe a three-phase model (in which stabilization
precedes and functional reintegration follows trauma processing) to be used in
treating complex PTSD in order to increase tolerability of the trauma-focused
interventions. This model has been developed based on clinical experience and
might be suitable for BPD patients. Korn (2009) found that treatment developed
to treat trauma, which corresponds to phase two in the model described here, is
essential in reducing PTSD symptoms.

In recent years more research has shown that PTSD can be successfully treated
in patients that suffer from invalidating comorbid disorders:
Van Rens e.a. (2011) found that treating patients suffering from both PTSD and
addiction according to evidence based techniques can be effective. Additionally
it has been demonstrated that EMDR therapy can be safely offered to PTSD
patients suffering from a psychotic disorder without having to make adaptations
to the protocol or the need to precede therapy by a stabilization phase. PTSD
symptoms decreased as a result of the therapy (van den Berg e.a., 2015), while
no adverse events or symptom exacerbation occurred (van den Berg e.a., 2015).
In a recent study, in which secondary analyses were performed on existing data,
CBT was found to be tolerable and effective in in reducing PTSD symptoms in
BPD/PTSD patients, even when no stabilization phase had been offered prior to
the start of treatment (Kredlow e.a., 2017). To our knowledge, no research has
yet been published on the effects of treating PTSD with EMDR in patients with a
comorbid BPD.

In short it is widely accepted that EMDR is effective in treating PTSD. EMDR
however is not commonly used in treating PTSD patients when there is a comorbid
BPD, even though it has been proven that PTSD can be successfully treated when
people suffer from severe comorbid disorders such as BPD. No studies to date
can confirm the justification of the aforementioned, which is why further
investigation is needed. In the current study it is examined if it is feasible
and effective to treat PTSD with EMDR in patients suffering from BPD.

We expect that EMDR treatment is feasible without a preceding stabilization
phase in BPD-PTSD patients. Additionally we expect that decrease of PTSD
symptoms will be significantly larger during EMDR treatment than during
treatment as usual (TAU).

A non-concurrent multiple baseline design is used in which PTSD symptoms are
treated with EMDR in fifteen patients suffering from both PTSD and BPD. In a
multiple baseline design patients serve as their own control. Patients will be
randomly assigned to one of three conditions.
In all conditions patients receive fifteen sessions of TAU in fifteen weeks,
while eight EMDR sessions will be added to this treatment. Conditions differ in
the timing of the start of EMDR sessions. EMDR sessions will start after having
had two (condition 1), four (condition 2) or six (condition 3) weeks of TAU.
During these eight weeks patients will receive both EMDR as well as TAU. In the
event a patient drops out early, he or she will be replaced by a new patient,
who is subsequently placed in the same condition. Information will be used in
the interpretation of the results. Every week the PCL-5, the KKL and the SDS
are going to be administered before a TAU session.

EMDR treatment during eight weeks.

Eight EMDR sessions will not provide a complete treatment for trauma in all
cases. Here, an amount of sessions is offered that has been found to be
effective in a comparable study. Target selection will take place in the first
session. A hierarchy of targets is made according to the intensity of stress
that is currently present when thinking of the trauma in question. The target
with the highest intensity will be treated first, then the target with the
second highest intensity and so on. Targets have to be desensitized to 0 in
order to be able to move on to the next target. Exceptions will be discussed.
Sessions last 90 minutes and will be sound recorded to improve adherence.
TAU sessions will be conducted according to the expertise of the therapist in
question and the principles of the Geïntegreerde Richtlijnbehandeling will be
incorporated. Sessions last 45 minutes.

Burden and risks:
*We are presenting patients with a type of treatment that still is a subject of
research. Patients will however be well informed (with emphasis on the fact
that this treatment will be offered as *an addition* and that the treatment
that will address their personality problems will be offered after the EMDR
treatment) and given the choice whether they want to participate.

*In some cases it may be possible that a patient cannot cope with the dynamics
that are brought on by the therapy. To monitor this, every session, attention
will be paid to adversities such as suicidal ideations, crises, substance abuse
or the tendency to terminate treatment. In case such adversities are to
suddenly occur, patients can contact their therapist or the *Crisis Management
Team*. Necessary actions will be taken in consultation with the head
practitioner.

*Patients will be asked to fill out lots of questions each week, which might be
considered to be a burden. This is why we chose to limit these questions to an
acceptable amount of 37 multiple choice items. This way we will only address
the main research question, while monitoring general functioning and possible
adversities.

Benefits:
*This research will be of value to the treatment of PTSD-BPD patients in the
future. If we can establish that it is safe and feasible to treat PTSD without
stabilization in this population, therapists will very likely be more inclined
to offer EMDR in an early stage of treatment. This will reduce suffering in
patients and can accelerate their recovery as a whole.

*Futher reasearch can shed more light on the aforementioned topic, from which
more advanced treatment options can be extracted.