Article

Impact of Co-Occurring Posttraumatic Stress Disorder on Suicidal Women With Borderline Personality Disorder

Department of Psychology, University of Washington, 3935 University Way NE, Seattle, WA 98105, USA.
American Journal of Psychiatry (Impact Factor: 12.3). 10/2010; 167(10):1210-7. DOI: 10.1176/appi.ajp.2010.09081213
Source: PubMed

ABSTRACT

The authors examined the impact of co-occurring posttraumatic stress disorder (PTSD) on women with borderline personality disorder who had attempted suicide in the preceding year.
Female borderline personality disorder outpatients (N=94) either with (N=53, 56.4%) or without PTSD (N=41, 43.6%) and with recent and repeated suicidal or self-injurious behavior were compared in nine areas of functioning.
Borderline personality disorder patients with and without PTSD differed in the lethality, intent, and triggers for intentional self-injury, trauma history, emotion regulation, and axis I comorbidity. The two groups did not differ in borderline personality disorder severity, axis II comorbidity, psychosocial functioning, or mental health or medical treatment utilization.
The results indicate greater impairment among individuals with both disorders and suggest that there are some unique features associated with co-occurring borderline personality disorder and PTSD that require further attention in assessment and treatment.

Full-text

Available from: Melanie Harned, Feb 01, 2015
Article
1210 ajp.psychiatryonline.org Am J Psychiatry 167:10, October 2010
to decrease the likelihood of attaining remission from bor-
derline personality disorder over a 10-year period (9).
In this study, we sought to replicate and extend previ-
ous work by examining the similarities and differences
between the clinical presentations of suicidal borderline
personality disorder outpatients with and without PTSD.
Nine groups of variables were investigated, including bor-
derline personality disorder severity, trauma history char-
acteristics, suicidal and nonsuicidal self-injury, comorbid
axis I disorders, comorbid axis II disorders, emotion regu-
lation and expressivity, psychosocial functioning, mental
health treatment utilization, and physical health status
and medical treatment utilization. Based on previous
research, we hypothesized that with the exception of bor-
derline personality disorder severity and comorbid axis II
disorders, borderline personality disorder patients with
PTSD would have greater impairment across each of these
domains compared to those without PTSD.
Method
Participants
Participants were 94 women with borderline personality disor-
der who were enrolled in a randomized controlled outpatient
psychotherapy outcome study. The measures included in our
analyses represent a portion of a larger baseline assessment.
Borderline personality disorder is associated with
high rates of comorbidity. Individuals with borderline
personality disorder meet criteria for an average of 3.4 to
4.2 lifetime axis I disorders (1, 2), including a high preva-
lence of posttraumatic stress disorder (PTSD), with esti-
mates as high as 56% (1, 3, 4). However, little research has
focused on the impact of PTSD on the clinical presenta-
tion, functioning, and behavioral patterns of individuals
with borderline personality disorder, and no studies have
examined these issues within the subgroup of suicidal
borderline personality disorder patients.
Previous research suggests that those with both bor-
derline personality disorder and PTSD tend to be more
impaired overall. Several studies have indicated that the
addition of PTSD does not signifi cantly alter the severity of
borderline personality disorder (5, 6), the number of axis II
disorders (6), social adjustment (6–8), general health sta-
tus (7), the frequency of suicide attempts (5, 8), or hostility
(7, 8). However, the addition of PTSD to borderline person-
ality disorder is associated with higher rates of other axis I
disorders, particularly anxiety disorders and major depres-
sion (7, 8), an increased risk of nonsuicidal self-injury (8),
more frequent inpatient psychiatric hospitalization (6),
poorer physical health (7), more impaired global function-
ing (6), and a higher rate of childhood sexual and physical
abuse (6). Moreover, the presence of PTSD has been found
(Am J Psychiatry 2010; 167:1210–1217)
Melanie S. H arned, Ph.D.
Shireen L. Rizvi, Ph.D.
Marsha M. Linehan, Ph.D.
Objective: The authors examined the
impact of co-occurring posttraumat-
ic stress disorder (PTSD) on women
with borderline personality disorder
who had attempted suicide in the
preceding year.
Method: Female borderline person-
ality disorder outpatients (N=94) ei-
ther with (N=53, 56.4%) or without
PTSD (N=41, 43.6%) and with recent
and repeated suicidal or self-injuri-
ous behavior were compared in nine
areas of functioning.
Results: Borderline personality disor-
der patients with and without PTSD
differed in the lethality, intent, and
triggers for intentional self-injury,
trauma history, emotion regula-
tion, and axis I comorbidity. The two
groups did not differ in borderline
personality disorder severity, axis II
comorbidity, psychosocial function-
ing, or mental health or medical
treatment utilization.
Conclusions: The results indicate
greater impairment among individu-
als with both disorders and suggest
that there are some unique features
associated with co-occurring border-
line personality disorder and PTSD
that require further attention in as-
sessment and treatment.
Impact of Co-Occurring Posttraumatic Stress Disorder on
Suicidal Women With Borderline Personality Disorder
This article is featured in this month’s AJP Audio and is discussed in an editorial by Dr. Eichelman (p. 1152).
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injury acts; 2) the suicide intent subscale (four items) assessing
the degree of suicidal intent associated with intentional self-in-
jury acts; 3) the rescue likelihood subscale (two items) assessing
the probability of intervention or discovery; 4) the interpersonal
infl uence subscale (eight items) assessing the use of intentional
self-injury as a way to get something from others (e.g., to get help,
to change others’ behavior); and 5) the emotion relief subscale
(six items) assessing the use of intentional self-injury as a way to
alleviate negative emotions. Finally, six items assessing the pres-
ence or absence of trauma-related triggers of intentional self-
injury were examined (e.g., fl ashbacks or nightmares, talking
about sexual abuse or rape).
Emotion regulation and expressivity. Three self-report mea-
sures of emotion regulation and expressivity were used: the Diffi -
culties in Emotion Regulation Scale (16), the Berkeley Expressivity
Questionnaire (17), and the State-Trait Anger Expression Inven-
tory (18).
Psychosocial functioning. Psychosocial functioning was as-
sessed using the Global Assessment of Functioning score from
the SCID-I as well as the global social adjustment score for the
best week in the past month (range, 1 [very good] to 5 [very poor])
from the Social History Interview (19). The Social History Inter-
view is an adaptation of both the psychosocial functioning por-
tion of the Social Adjustment Scale and the Longitudinal Interval
Follow-Up Evaluation base schedule (20). The Inventory of Inter-
personal Problems (21) was used to measure self-reported diffi -
culties in interpersonal relationships.
Mental health treatment utilization. The Treatment History
Interview (22) was used to measure participants’ utilization of a
variety of mental health services during the year prior to entering
the study, including inpatient psychiatric hospitalizations, emer-
gency department visits for psychological reasons, outpatient
mental health visits, and prescribed psychotropic medications.
Physical health status and medical treatment utilization.
A medical health history questionnaire measured participants
self-reported history of current and lifetime medical problems and
general health status (ranging from 0 [poor] to 2 [good]). The Treat-
ment History Interview assessed medical treatment utilization in
the past year, including hospitalizations for medical reasons, emer-
gency department visits for medical reasons, doctor visits for medi-
cal reasons, and prescribed nonpsychotropic medications.
Statistical Analysis
Dependent variables were grouped into the nine theoretically
related categories listed above. For each category, a multivari-
ate analysis of variance (MANOVA) was run, and if a signifi cant
multivariate effect for PTSD status was found, univariate tests of
between-subject effects for each of the dependent variables were
examined. Effect sizes are presented as partial eta-squared values
(η
2
), for which recommended cut-offs for interpretation are 0.01
(small effect), 0.06 (medium effect), and 0.14 (large effect) (23).
Results
Sample Characteristics
Of the 94 participants, 53 (56.4%) met diagnostic criteria for
current PTSD. Patients with and without PTSD did not signifi -
cantly differ on any demographic characteristics (Table 1).
Comparisons of Borderline Personality Disorder
Patients With and Without PTSD
Figure 1 summarizes the results of the between-group
comparisons.
To be included in this study, patients had to meet criteria for
borderline personality disorder; be 18–60 years of age; be
female; have at least two intentional self-injury acts (i.e., suicide
attempts or nonsuicidal self-injury) in the past 5 years, includ-
ing at least one in the 8-week period prior to entering the study;
and have at least one suicide attempt in the past year. (One par-
ticipant was included in the study who had a suicide attempt
in the past 8 weeks but no additional intentional self-injury in
the past 5 years.) Participants were excluded if they met criteria
for a psychotic disorder, mental retardation, or bipolar disorder;
had a seizure disorder requiring medication; were mandated to
treatment; or required primary treatment for another debilitat-
ing condition. All participants read and signed the informed
consent form after the study procedures were explained to them.
Procedures
After an initial telephone screening, potential participants under-
went a series of in-person assessments for study eligibility and to
gather more detailed diagnostic and pretreatment information. All
assessments were conducted by independent clinical assessors who
were trained on interview measures by the instrument developers or
an approved trainer and then evaluated for reliability.
Measures
Axis II disorders. The Structured Clinical Interview for DSM-IV
Axis II Personality Disorders (10) was used to diagnose borderline
personality disorder and to compute the number of criteria met.
The International Personality Disorder Examination (11) was
used to confi rm the borderline personality disorder diagnosis,
to generate a borderline personality disorder dimensional score
(range of possible scores, 0–18), and to assess all other axis II di-
agnoses.
Axis I disorders. The Structured Clinical Interview for DSM-IV
Axis I Disorders (SCID-I; 12) was used to diagnose mood, anxiety,
eating, and substance use disorders.
Trauma history. The self-report Traumatic Life Events Question-
naire (13) was used to assess lifetime history of 22 types of trau-
matic events. The three-item Childhood Experiences Question-
naire (14) was used to assess self-reported history of three types
of childhood sexual abuse (unwanted sexual experiences with a
person at least 5 years older with clothes on, with clothes off, and
with sexual intercourse). To prevent overlap across instruments,
we removed the one item from the Traumatic Life Events Ques-
tionnaire that assessed childhood sexual abuse. For both instru-
ments, participants reported the frequency of each type of trau-
matic event on a 7-point Likert scale ranging from 0 (never) to 6
(more than fi ve times) and, when relevant, the age at onset. Data
from both instruments were combined to yield the following: 1)
the age at onset of the earliest traumatic event, 2) the frequency
of crime events (four items; e.g., robbery, stalking), 3) the fre-
quency of physical abuse or assault events (two items: childhood
physical abuse and intimate partner violence), 4) the frequency
of unwanted sexual events (seven items; e.g., childhood sexual
abuse, adult rape, sexual harassment), 5) the frequency of general
disaster events (four items; e.g., natural disaster, motor vehicle
accident), 6) the frequency of events involving witnessing trauma
(four items; e.g., witnessing domestic violence, seeing another
person attacked), 7) the frequency of other types of traumatic
events (four items; e.g., life-threatening illness, miscarriage), and
8) the total number of all types of traumatic events.
Suicidal and nonsuicidal self-injury. The Suicide Attempt
Self-Injury Interview (15) was used to assess the frequency, in-
tent, and severity of intentional self-injury (i.e., suicide attempts
and nonsuicidal self-injury) that occurred in the past year. Several
subscales were also used: 1) the lethality subscale (three items)
assessing the severity and potential lethality of intentional self-
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1212 ajp.psychiatryonline.org Am J Psychiatry 167:10, October 2010
of borderline personality disorder criteria met and the bor-
derline personality disorder dimensional score.
Trauma history. There was a signifi cant multivariate effect
for PTSD status (Wilkss lambda=0.78; F=2.67, df=7, 68,
p=0.02) when comparing the two groups on trauma histo-
ry variables. Borderline personality disorder patients with
PTSD reported a greater number of total traumatic events
and unwanted sexual events (Table 2).
Suicidal and nonsuicidal self-injury. There was a signifi -
cant multivariate effect for PTSD status on suicide and
nonsuicidal self-injury variables (Wilkss lambda=0.67;
F=2.98, df=13, 78, p=0.001). The patients with PTSD re-
ported less suicide intent when engaging in intentional
self-injury (i.e., suicide attempts and nonsuicidal self-in-
jury), lower lethality associated with intentional self-inju-
ry, greater use of intentional self-injury for interpersonal
infl uence reasons, and a higher frequency of intentional
self-injury being triggered by fl ashbacks or nightmares,
thoughts about sexual abuse or rape, and talking to some-
one about sexual abuse or rape (Table 2). There was also
a trend indicating that patients with PTSD had engaged
in more frequent nonsuicidal self-injury in the past year
(29.7 acts compared with 12.9 acts, p=0.07).
To better understand these fi ndings, a post hoc
MANOVA was conducted that included these same
variables but considered only suicide attempts (that is,
nonsuicidal self-injury acts were excluded). There was
a signifi cant multivariate effect for PTSD status in this
model (Wilkss lambda=0.68; F=3.00, df=12, 76, p=0.002).
The results indicated that patients with PTSD were more
likely to attempt suicide for interpersonal infl uence rea-
TABLE 1. Demographic Characteristics of 94 Women With Borderline Personality Disorder With and Without PTSD
a
Borderline Personality Disorder Subgroup
Characteristic PTSD Present (N=53) PTSD Absent (N=41) Total (N=94)
N%N%N%
Race
White 39 75.0 27 67.5 66 71.7
Biracial 10 19.2 9 22.5 19 20.7
Asian American 2 3.8 3 7.5 5 5.4
Other 1 1.9 1 2.5 2 2.2
Hispanic ethnicity 7 13.2 2 4.9 9 9.6
Single, divorced, separated, or widowed 42 79.2 37 92.5 79 84.9
Education
<High school 3 5.7 4 9.8 7 7.4
High school graduate or equivalency 4 7.5 4 9.7 8 8.5
Some college or technical school 32 60.4 23 56.1 55 58.5
College graduate 14 26.4 10 24.4 24 25.5
Annual income
<$15,000 37 71.2 22 53.7 59 63.4
$15,000–$30,000 11 21.2 13 31.7 24 25.8
>$30,000 4 7.7 6 14.6 10 10.8
Mean SD Mean SD Mean SD
Age 30.5 8.6 29.8 9.3 30.2 8.8
a
No between-group differences were statistically signifi cant. Analyses were conducted using the t test, the chi-square test, and Fisher’s
exact test as appropriate. Valid percentages (i.e., not including missing data) are presented.
FIGURE 1. Summary of Major Findings in Comparisons of
94 Women With Borderline Personality Disorder With and
Without PTSD
a
Finding approached signifi cance (p=0.07).
Borderline Personality Disorder With PTSD >
Borderline Personality Disorder Without PTSD
• Total number of lifetime traumatic events
• Number of lifetime unwanted sexual events
• Frequency of nonsuicidal self-injury
a
• Use of intentional self-injury for interpersonal influence
• Trauma-related triggers of intentional self-injury, including
flashbacks/nightmares, thoughts about sexual abuse/rape,
and talking to someone about sexual abuse/rape
• Rates of comorbid axis I disorders, specifically panic
disorder, agoraphobia, and obsessive-compulsive disorder
• Emotion dysregulation
• Anger suppression
Borderline Personality Disorder With PTSD <
Borderline Personality Disorder Without PTSD
• Expression of positive emotions
Borderline Personality Disorder With PTSD =
Borderline Personality Disorder Without PTSD
• Borderline personality disorder severity
• Frequency, intent, and lethality of suicide attempts
• Use of intentional self-injury for emotion relief
• Rates of comorbid axis II disorders
• Expression of negative emotions
• Psychosocial functioning
• Mental health treatment utilization
• Physical health status
• Medical treatment utilization
Borderline personality disorder severity. There was no sig-
nifi cant multivariate effect for PTSD status on the number
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TABLE 2. Comparisons of 94 Women With Borderline Personality Disorder With and Without PTSD on Trauma History,
Suicidal and Nonsuicidal Self-Injury, Current Axis I Disorders, and Emotion Regulation and Expressivity
Borderline Personality Disorder Subgroup
PTSD Present (N=53) PTSD Absent (N=41) Analysis
a
Variable Mean SD Mean SD p η
2
Trauma history
Age at fi rst trauma (years) 7.42 4.19 9.48 8.65 0.17 0.03
Crime events 3.87 3.15 2.48 2.89 0.06 0.05
Physical abuse or assault events 5.29 4.23 3.48 3.72 0.06 0.05
Unwanted sexual events 16.58 9.39 9.35 10.28 <0.01 0.12
General disaster events 1.84 2.03 2.35 2.29 0.31 0.01
Events involving witnessing trauma 6.16 4.59 5.42 3.47 0.45 0.01
Other types of traumatic events 2.31 2.58 2.61 3.57 0.67 <0.01
Total traumatic events 36.04 15.59 25.71 19.69 0.01 0.08
Suicidal and nonsuicidal self-injury:
Suicide Attempt Self-Injury Interview
Suicide attempts, past year 3.00 2.67 3.17 5.09 0.83 0.00
Nonsuicidal self-injury acts, past year 29.73 48.61 12.92 34.52 0.07 0.04
Lethality subscale 3.46 2.86 5.14 3.99 0.02 0.06
Suicide intent subscale 3.28 1.97 4.52 2.51 <0.01 0.07
Rescue likelihood subscale 5.78 0.94 5.89 1.09 0.64 <0.01
Interpersonal infl uence subscale 1.28 1.45 0.74 1.05 0.05 0.04
Emotion relief subscale 3.52 1.39 3.18 1.48 0.26 0.01
Feeling unreal or disconnected 0.67 0.42 0.50 0.48 0.08 0.03
Flashbacks or nightmares 0.44 0.47 0.08 0.22 <0.001 0.18
Thoughts about sexual abuse or rape 0.30 0.41 0.08 0.25 <0.01 0.10
Thoughts about physical abuse or assault 0.15 0.33 0.07 0.24 0.23 0.02
Talked to someone about sexual abuse or rape 0.11 0.25 0.03 0.16 0.05 0.04
Talked to therapist about sexual abuse or rape 0.04 0.13 0.00 0.00 0.07 0.04
Comorbid axis I disorders
b
Major depression 0.77 0.42 0.63 0.49 0.14 0.02
Panic disorder 0.53 0.50 0.22 0.42 <0.01 0.10
Agoraphobia without panic disorder 0.09 0.29 0.00 0.00 0.04 0.04
Social phobia 0.32 0.47 0.29 0.46 0.77 0.001
Specifi c phobia 0.24 0.43 0.32 0.47 0.45 0.01
Obsessive-compulsive disorder 0.21 0.41 0.00 0.00 <0.01 0.10
Generalized anxiety disorder 0.06 0.23 0.15 0.36 0.15 0.02
Eating disorders 0.21 0.41 0.07 0.26 0.07 0.04
Substance use disorders 0.42 0.50 0.34 0.48 0.47 0.01
Emotion regulation and expressivity
Diffi culties in Emotion Regulation Scale score 131.64 20.29 119.51 21.02 <0.01 0.08
Berkeley Expressivity Questionnaire
Negative expressivity subscore 3.96 1.09 4.04 1.15 0.75 0.001
Positive expressivity subscore 5.19 1.18 5.68 1.02 0.04 0.05
State-Trait Anger Expression Inventory
Anger–in score 23.06 4.02 21.00 4.90 0.03 0.05
Controlled anger score 20.13 5.39 17.78 4.93 0.03 0.05
Anger–out score 17.91 5.55 20.10 5.98 0.07 0.04
Anger expression score 36.83 11.35 39.32 10.75 0.28 0.01
a
Results are from univariate tests of between-subject effects for the four multivariate analyses of variance (MANOVAs) that yielded
signifi cant multivariate effects for PTSD status. Because of missing data on some measures, the Ns for each MANOVA varied from 45 to 53
in the group with borderline personality disorder only and from 31 to 41 in the group with borderline personality disorder and PTSD.
b
For comorbid axis I disorders, the data were analyzed as continuous variables (ranging from 0 to 1) representing the proportion of
participants meeting diagnostic criteria for the disorder.
sons (p=0.01, η
2
=0.07) and that suicide attempts were
more likely to be preceded by fl ashbacks or nightmares
(p<0.001, η
2
=0.15) and thoughts about sexual abuse or
rape (p=0.001, η
2
=0.12). Notably, borderline personality
disorder patients with and without PTSD did not differ
in terms of the frequency, intent, or lethality of suicide
attempts.
Comorbid axis I disorders. There was a signifi cant multi-
variate effect for PTSD status on current axis I disorders,
excluding PTSD (Wilkss lambda=0.72; F=3.67, df=9, 84,
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these trauma-related cues. This may suggest that for some
individuals with these co-occurring disorders, addressing
PTSD criterion behaviors (e.g., trauma cue reactivity) may
be necessary in order for functionally related suicidal and
self-injurious behavior to decrease. Short-term solutions,
such as distress tolerance skills to tolerate diffi cult emo-
tions and substituting alternative, nonharmful behaviors
to manage triggers in more adaptive ways, may be useful
in this area (24). However, the long-term solution for this
problem will likely require the resolution of PTSD through
more targeted treatments.
Patients with PTSD scored signifi cantly higher on mea-
sures of emotion dysregulation and anger suppression
and lower on expression of positive emotions. Diffi culty
expressing positive emotions is consistent with the PTSD
diagnostic criterion of restricted range of affect, which
typically involves an inability to experience loving and
intimate feelings. In addition, theories of PTSD empha-
size the extremes in emotional responding that are char-
acteristic of this disorder, including an intrusion phase of
intense emotional experiencing (e.g., fl ashbacks, distress-
ing memories of the trauma) that may trigger emotional
numbing (25). This vacillation between overwhelming
emotions and emotional numbing that is common in
PTSD may exacerbate the emotion dysregulation that is a
core feature of borderline personality disorder. Moreover,
this increased emotion dysregulation may contribute to
the higher rate of nonsuicidal self-injury among border-
line personality disorder patients with PTSD given that
nonsuicidal self-injury most often functions to alleviate
negative affect (26).
Patients with both borderline personality disorder and
PTSD were more impaired in terms of axis I comorbidity.
They were more likely to meet criteria for panic disorder
(53% compared with 22%), obsessive-compulsive disor-
der (21% compared with 0%), and agoraphobia without
panic disorder (9% compared with 0%). This is consistent
with previous research demonstrating that PTSD has the
highest and most diverse rate of comorbid disorders (27)
as well as data from the National Comorbidity Survey indi-
cating that women with PTSD are at particularly high risk
for developing co-occurring panic disorder (28). However,
in contrast to fi ndings of previous research (29), we did
not fi nd that PTSD was associated with a higher preva-
lence of any mood, substance use, or eating disorder. This
discrepancy is likely due to the generally high rate of axis
I comorbidity found in individuals with borderline per-
sonality disorder (2, 30), as in our sample—in which, for
example, high rates of co-occurring major depressive dis-
order (63%–77%) and substance use disorders (34%–42%)
were observed. Taken together, these fi ndings suggest that
among women with borderline personality disorder who
already exhibit high rates of axis I comorbidity, PTSD fur-
ther increases the risk of other specifi c anxiety disorders.
Women with borderline personality disorder who had
PTSD reported signifi cantly more total traumatic events
p=0.001). Patients with PTSD had higher rates of panic dis-
order, agoraphobia without panic disorder, and obsessive-
compulsive disorder (Table 2).
Comorbid axis II disorders. The multivariate effect of
PTSD status on current rates of axis II disorders (excluding
borderline personality disorder) was nonsignifi cant.
Emotion regulation and expressivity. There was a signifi -
cant multivariate effect for PTSD status on measures of
emotion regulation and expressivity (Wilkss lambda=0.82;
F=3.29, df=6, 87, p=0.006). Patients with PTSD reported
greater emotion dysregulation and anger suppression and
less expression of positive emotions (Table 2).
Psychosocial functioning. The multivariate effect of PTSD
status on measures of psychosocial functioning was non-
signifi cant.
Mental health treatment utilization. The multivariate ef-
fect of PTSD status on mental health treatment utilization
in the past year was nonsignifi cant.
Physical health status and medical treatment utilization.
There was a nonsignifi cant multivariate effect for PTSD
status on measures of physical health status and medical
treatment utilization.
Discussion
This study adds to a growing body of evidence indi-
cating that individuals with borderline personality dis-
order and co-occurring PTSD are likely to have more
complex clinical presentations than those without PTSD.
In patients with both disorders, scores for suicide intent
and lethality were lower when averaged across both sui-
cide attempts and nonsuicidal self-injury episodes. This
is likely accounted for by the trend-level fi nding indicat-
ing that patients with both disorders engaged in more
frequent nonsuicidal self-injury. When comparing suicide
intent and lethality for suicide attempts only, there was
no difference between the two groups. This is in contrast
to a previous study (14) fi nding that women with border-
line personality disorder who had a history of childhood
sexual abuse reported more lethal self-injurious behavior
than those without such a history, suggesting that it may
be childhood sexual abuse, not PTSD, that is predictive of
more lethal self-injurious behavior in this population.
Borderline personality disorder patients with and with-
out PTSD also differed in the function and triggers of
intentional self-injury. Those with PTSD were more likely
to report engaging in intentional self-injury as a way to
infl uence others. They were also more likely to endorse
a variety of trauma-related triggers for their episodes of
intentional self-injury, including fl ashbacks, thoughts
about sexual trauma, and talking to someone about
sexual trauma. It is possible that women with both dis-
orders engage in higher rates of nonsuicidal self-injury
because they have a greater number of potential triggers
for these behaviors as well as a heightened reactivity to
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HARNED, RIZVI, AND LINEHAN
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1215
the use of a suicidal sample, as the presence of a recent
suicide attempt signifi cantly lowers indices of functioning
and may have led to a fl oor effect. The lack of between-
group differences in treatment utilization is also dis-
crepant with previous research (6, 7) and may be due to
a number of factors. First, the sample used for this study
was treatment-seeking and thus was self-selecting based
on this variable. Second, given previous research that has
indicated high rates of treatment utilization in borderline
personality disorder compared to other disorders (31), it
is also possible that a ceiling effect exists. For example,
the majority of participants in our sample had gone to an
emergency department for psychological reasons and had
at least one psychiatric hospitalization in the past year.
Finally, it is possible that the addition of PTSD to border-
line personality disorder does not account for an increase
in treatment-seeking behavior.
This study has important limitations. Because our sam-
ple included only female patients, only treatment-seeking
patients, and only patients with recent and chronic sui-
cidal and/or nonsuicidal self-injury and excluded patients
with bipolar or psychotic disorders, our results may not be
representative of individuals with borderline personality
disorder and PTSD more broadly.
Our results have both theoretical and clinical implica-
tions. This study provides additional empirical support
for the current diagnostic system, which considers bor-
derline personality disorder and PTSD to be separate,
although often co-occurring, disorders. Some research-
ers have suggested that borderline personality disorder
as well as nearly twice as many past unwanted sexual
experiences (e.g., childhood sexual abuse, adult rape, sex-
ual harassment) as their counterparts without PTSD (16.6
compared with 9.4), a fi nding consistent with previous
research (6). Women with or without PTSD reported a high
total incidence of trauma exposure, averaging 26 to 36 life-
time traumatic events. It will be important to determine
the factors that protect some individuals with borderline
personality disorder from developing PTSD despite such
high rates of trauma exposure.
As hypothesized, no differences were found between
the groups on borderline personality disorder severity
or the presence of other axis II disorders. These fi nd-
ings are consistent with previous research that has not
found borderline personality disorder patients with and
without PTSD to differ in terms of the number of bor-
derline personality disorder criteria met (5, 6) or the
number of co-occurring axis II disorders (6). Our fi nd-
ings extend this previous research to indicate also that
the two groups exhibit comparable rates of each specifi c
axis II disorder.
Contrary to our hypotheses, borderline personality
disorder patients with and without PTSD also did not dif-
fer in terms of overall psychosocial functioning, mental
health treatment utilization, or physical health and medi-
cal treatment utilization. The fi ndings related to psycho-
social functioning differ from previous research that has
found higher levels of psychosocial impairment in bor-
derline personality disorder patients with PTSD than in
those without PTSD (6). This discrepancy is likely due to
Mary: Borderline Personality Disorder With PTSD
Mary sought treatment because, she said, “I am cutting
on myself, having flashbacks, feeling suicidal—if anything
goes wrong, [suicide] is the first solution I think of.” Mary
was severely and repeatedly sexually and physically abused
by her parents until age 12, when she was removed from
their custody after attempting suicide. She developed
severe PTSD during her childhood as a result of this abuse,
and it had never remitted despite her spending much of
her adolescence and adulthood living in inpatient and
residential treatment facilities. As an adult, Mary had also
been raped and beaten by a stranger and been the victim
of a robbery. She had attempted suicide more than 20
times in her life via cutting and overdosing, and she was
engaging in nonsuicidal cutting approximately two times
per week. Mary’s suicidal and nonsuicidal self-injury was
primarily triggered by flashbacks and functioned to
decrease her anxiety and provide her with an escape from
the intense intrusive memories of her childhood abuse.
Laura: Borderline Personality Disorder Without PTSD
Explaining her reason for seeking treatment, Laura said,
“I have tried to kill myself two times [in the past 3 months]
and I am ready to make a change.” She had attempted
suicide three times in her life via overdosing and had hit
herself to the point of bruising about six times. Each of
these episodes was prompted by intense anger caused by
interpersonal conflict, and both recent suicide attempts
had occurred after fights with her boyfriend. Although she
did not meet criteria for PTSD, Laura reported experiencing
several traumatic events, including being stalked and
physically threatened as an adult, a serious motor vehicle
accident, and several natural disasters. However, she
reported the most distress in relation to several subthresh-
old “traumas,” including chronic invalidation by her
parents and significant and protracted conflict with
members of her extended family. As a result of these
experiences, Laura exhibited pervasive distrust and
suspiciousness of others, which was the cause of much
instability and conflict in her relationships. She also experi-
enced considerable self-doubt, which primarily manifested
as generalized anxiety and worry about her ability to
succeed in school and work contexts.
Patient Perspectives
Page 6
PTSD IN SUICIDAL WOMEN WITH BORDERLINE PERSONALITY DISORDER
1216 ajp.psychiatryonline.org Am J Psychiatry 167:10, October 2010
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AE, Grilo CM, McGlashan TH, Gunderson JG, Bender DS, Zanari-
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with borderline personality disorder (BPD) with posttraumatic
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ality disorder. Compr Psychiatry 2006; 47:357–361
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9. Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR: Pre-
diction of the 10-year course of borderline personality disor-
der. Am J Psychiatry 2006; 163:827–832
10. First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin L:
Structured Clinical Interview for DSM-IV Axis II Personality Dis-
orders (SCID-II): User’s Guide. Washington, DC, American Psy-
chiatric Press, 1997
11. Loranger AW: International Personality Disorder Examination
(IPDE) Manual. White Plains, NY, Cornell Medical Center, 1995
12. First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clini-
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P), version 2. New York, New York State Psychiatric Institute,
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son SB, Burns K: Development and preliminary validation
of a brief broad-spectrum measure of trauma exposure: the
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12:210–224
14. Wagner AW, Linehan MM: Relationship between childhood
sexual abuse and topography of parasuicide among women
with borderline personality disorder. J Pers Disord 1994; 8:
1–9
15. Linehan MM, Comtois KA, Brown MZ, Heard HL, Wagner A:
Suicide Attempt Self-Injury Interview (SASII): development, re-
liability, and validity of a scale to assess suicide attempts and
intentional self-injury. Psychol Assess 2006; 18:303–312
16. Gratz KL, Roemer L: Multidimensional assessment of emotion
regulation and dysregulation: development, factor structure,
and initial validation of the Diffi culties in Emotion Regulation
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report factors and their correlates. Pers Individ Diff 1995;
19:555–568
18. Spielberger CD, Krasner SS, Solomon EP: The experience, ex-
pression, and control of anger, in Health Psychology: Indi-
vidual Differences and Stress. Edited by Janisse MP. New York,
Springer Verlag, 1988, pp 89–108
19. Linehan MM, Heard HL: Social History Interview (SHI). Seattle,
University of Washington, 1994
20. Keller MB, Lavori PW, Friedman B, Nielsen E, Endicott J, McDon-
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is better described as a trauma-related condition known
as complex PTSD” (32, 33). However, conceptualizing
borderline personality disorder and PTSD as the same
disorder would disregard the important distinctions that
exist between these two groups. Clinically, given that
patients with both disorders appear to have a particularly
severe and complex overall presentation, treatments for
this population must be able to address these unique
features (34). Results from two previous studies suggest
that the addition of a high level of borderline personal-
ity disorder characteristics, although related to greater
overall impairment, did not prevent individuals from
making signifi cant gains with cognitive-behavioral treat-
ments for PTSD (35, 36). However, these studies excluded
suicidal and/or self-injuring patients and did not assess
for the full borderline personality disorder diagnosis.
In addition, no research has yet examined whether the
presence of PTSD signifi cantly alters the course or out-
come of treatments for borderline personality disorder.
Thus, it will be important for future research to deter-
mine whether individuals with co-occurring borderline
personality disorder and PTSD fare worse in treatments
for either disorder, particularly among those who are sui-
cidal or self-injuring.
Presented in part at the 42nd annual meeting of the Associa-
tion for Behavioral and Cognitive Therapies, Orlando, Fla., Novem-
ber 13–16, 2008. Received Aug. 25, 2009; revisions received Feb.
9 and April 6, 2010; accepted April 14, 2010 (doi: 10.1176/appi.
ajp.2010.09081213). From the Department of Psychology, University
of Washington; and the Graduate School of Applied and Professional
Psychology, Rutgers University, Piscataway, N.J. Address correspon-
dence and reprint requests to Dr. Harned, Department of Psychol-
ogy, University of Washington, 3935 University Way NE, Seattle, WA
98105; mharned@u.washington.edu (e-mail).
The authors do consulting and workshops for Behavioral Tech, LLC.
Dr. Linehan receives royalties for products distributed by Behavioral
Tech for which she contributed to the development and royalties
from Guilford Press.
Supported by NIMH grant MH-34486 to Dr. Linehan.
The authors thank the clients, therapists, assessors, and staff at
the Behavioral Research and Therapy Clinics for their help with this
research.
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  • Source
    • "PTSD is associated with greater impairment among individuals with BPD (Bolton, Mueser, & Rosenberg, 2006; Zlotnick et al., 2003; Zlotnick, Franklin, & Zimmerman, 2002), including increased risk for suicidal behavior and non-suicidal self-injury (NSSI) (Harned, Rizvi, & Linehan, 2010b) and lower likelihood of remittance from BPD (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006). One possible explanation for the higher clinical severity found in individuals with BPD and comorbid PTSD versus those individuals with BPD without PTSD is that childhood trauma and PTSD may maintain or exacerbate BPD by further intensifying emotion dysregulation and increasing the frequency of impulsive and self-destructive behaviors, which are among the core features of the disorder (Harned et al., 2010b). For example, suicidal behaviors and NSSI may function as a way to cope with intense negative affect and cognitions associated with PTSD and trauma (Harned, 2013). "
    [Show abstract] [Hide abstract] ABSTRACT: The aim of this study was to determine the influence of posttraumatic stress disorder (PTSD) on treatment outcomes in patients with borderline personality disorder (BPD). Participants were 180 individuals diagnosed with BPD enrolled in a randomized controlled trial that compared the clinical and cost effectiveness of dialectical behavior therapy (DBT) and general psychiatric management (GPM). Multilevel linear models and generalized linear models were used to compare clinical outcomes of BPD patients with and without PTSD. BPD patients with comorbid PTSD reported significantly higher levels of global psychological distress at baseline and end of treatment compared to their non-PTSD counterparts. Both groups evidenced comparable rates of change on suicide attempts and non-suicidal self-injury (NSSI), global psychological distress, and BPD symptoms over the course of treatment and post-treatment follow-up. DBT and GPM were effective for BPD patients with and without PTSD across a broad range of outcomes.
    Full-text · Article · Jan 2016 · Journal of Personality Disorders
  • Source
    • "Patients suffering from PTSD in addition to BPD displayed a higher frequency (29.7 acts compared to 12.9 acts, p = .07) of nonsuicidal self-harm than patients with BPD alone (Harned, Rizvi, & Linehan, 2010). It is not yet clear, however, whether PTSD is an independent predictor of suicidal behavior when co-occurring with BPD. "
    [Show abstract] [Hide abstract] ABSTRACT: We investigated whether posttraumatic stress disorder (PTSD) was predictor of suicidal behavior even when adjusting for comorbid borderline personality disorder (BPD) and other salient risk factors. To study this, we randomly selected 308 patients admitted to a psychiatric hospital because of suicide risk. Baseline interviews were performed within the first days of the stay. Information concerning the number of self-harm admissions to general hospitals over the subsequent 6 months was retrieved through linkage with the regional hospital registers. A censored regression analysis of hospital admissions for self-harm indicated significant associations with both PTSD (β = .21, p < .001) and BPD (β = .27, p < .001). A structural model comprising two latent BPD factors, dysregulation and relationship problems, as well as PTSD and several other variables, demonstrated that PTSD was an important correlate of the number of self-harm admissions to general hospitals (B = 1.52, p < .01). Dysregulation was associated directly with self-harm (B = 0.28, p < .05), and also through PTSD. These results suggested that PTSD and related dysregulation problems could be important treatment targets for a reduction in the risk of severe self-harm in high-risk psychiatric patients.
    Full-text · Article · Nov 2015 · Journal of Traumatic Stress
  • Source
    • "Findings from other clinical studies, however, suggest that the impact of this comorbidity may include exacerbation of core symptoms of these two disorders. Particularly, whereas some findings suggest lesser or similar levels of emotion dysregulation-related symptoms among individuals with this comorbidity versus BPD only [17, 18] , other findings suggest that comorbid PTSD may play an exacerbating role in the expression of affective instability [19, 20], and on the lethality, intent, and triggers for intentional self-injury [21] in BPD. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: The comorbidity of borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is frequent, yet not well understood. The influence of childhood sexual abuse (CSA) in the development of this comorbidity has been a focus of prior clinical studies, but empirical evidence to generalize this focus to the broader population is lacking. Primary aims of the present study included evaluation of: (a) the association of this comorbidity with decrements in health-related quality of life (HRQOL) and (b) the importance of CSA as a predictive factor for this comorbidity in a general population sample. Methods: We utilized data from Wave 2 of the National Epidemiological Survey on Alcohol and Related Conditions, a nationally representative face-to-face survey evaluating mental health in the non-institutionalized adult population of the United States. Data from respondents who met criteria for BPD and/or PTSD were analyzed (N = 4104) to assess potential associations between and among lifetime BPD-PTSD comorbidity, CSA, gender, healthcare usage, and mental and physical HRQOL. Results: Lifetime comorbidity of BPD and PTSD was associated with more dysfunction than either individual disorder; and the factors of gender, age, and CSA exhibited significant effects in the prediction of this comorbidity and associated decrements in HRQOL. Conclusions: Results support the measured focus on CSA as an important, but not necessary, etiologic factor and emphasize this comorbidity as a source of greater suffering and public health burden than either BPD or PTSD alone. The differential impact of these disorders occurring alone versus in comorbid form highlights the importance of diagnosing both BPD and PTSD and attending to lifetime comorbidity.
    Full-text · Article · Sep 2015
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