Interventions with a primary focus on Phase 2

Personality disorder integrated care pathway
NHS Highland

People with personality disorder will often have a history of abuse. Around three quarters of people with borderline personality disorder will have recallable abuse and about half of people with BPD will meet criteria for post-traumatic stress disorder (PTSD). Some have suggested that those people exposed to repeated, expected trauma which is perceived as inescapable, can develop a condition known as complex PTSD. Although this disorder is not specifically described in ICD-10 or DSM-5, it is frequently written about in mainstream journals. Its diagnostic criteria are similar to borderline personality disorder and treatment approaches are similar, although the evidence base is much smaller. The clinical utility of separating these conditions is unclear.

Eye Movement Desensitisation and Reprocessing (EMDR) and Trauma-focused Cognitive Behaviour Therapy (tfCBT) have been included in this section because of the high rates of PTSD in the personality disorder patient group. However, strictly speaking, they are not personality disorder-specific interventions, but were developed for people with PTSD (with or without personality disorder). Although Phase 2 treatment will often concern post-traumatic problems, sometimes the work will deal with other difficulties in long-standing patterns of behaviour and thinking. Integration or “joining-up” of the different phases of treatment in a timely manner is crucial. The commencement of phase 2 treatment should occur when the patient is “stable enough”.

Although each decision should be made on a case by case basis, the criteria used to determine readiness for trauma work within the DBT-PE protocol provides a reasonable guide:

  • Not at imminent risk of suicide (by next month or by next session)
  • No life-threatening behaviour for a period of 2 months or so
  • Ability to control life-threatening behaviours in the presence of cues for those behaviors
  • No serious therapy interfering behaviour
  • Trauma work is the patients highest priority treatment target
  • The patient wishes to engage in the work at this point
  • Ability and willingness to experience intense emotions without escaping
Very often, progression through phases is not uni-directional and many people will require short periods of restabilisation during later phases of treatment.

Dialectical Behaviour Therapy—Prolonged Exposure (DBT-PE)

What is it:

Treatment generally lasts for 6 months to 1 year. 

DBT is a structured intensive CBT based Phase 1, tier 3 treatment for people with severe borderline personality disorder. Each week the patient attends a 2 hour skills training session in which 2 DBT therapists teach skills of mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness. It takes 26 weeks to
complete a cycle of the 4 skills modules. Patients often complete 2 cycles of skills training. In addition to the skills training, each patient attends for 1 hour of individual therapy each week with the same therapist. This involves the patient recording daily emotions, behaviours and thoughts on a diary card which is reviewed in session with a view to enhancing and generalising skills.

  • DBT is not used as a stand-alone treatment but represents part of an overall care plan.
  • DBT is delivered by the Personality Disorder Service in Inverness, serving the whole of NHS Highland.

Around half of patients with borderline personality disorder will also meet diagnostic criteria for post-traumatic stress disorder. Once stabilisation has occurred with standard DBT, it may be appropriate to consider using the DBT-Prolonged Exposure (DBT-PE) protocol for Phase 2 of treatment (trauma work).

DBT-PE is an integration of DBT and standard Prolonged Exposure (a CBT approach with an evidence base for treating PTSD). DBT-PE is delivered within the individual component of DBT. The sessions will typically last 90 minutes to 2 hours, compared with the 1 hour sessions of the standard DBT individual component. The two main components of DBT-PE are imaginal exposure and in vivo exposure.

Imaginal exposure involves the patient voicing the narrative of relevant past traumatic events and listening to recordings of the narrative between sessions until habituation to the associated emotion occurs. In vivo exposure involves the construction of a hierarchy of distressing situations which are avoided because of past trauma events and exposure to the distressing situations. The aim is habituation to the associated emotions and reduction in behavioural and cognitive avoidance.

DBT-PE is conceptualised as a treatment strategy within DBT and patients engage with all usual components of DBT in DBT for the duration. If behavioural destabilisation occurs during DBT-PE, the treatment focus will return to Phase 1 or standard DBT.

Who is it for:

Individuals with severe borderline personality disorder and post-traumatic symptoms. Individuals need to be on the Care Programme Approach for the duration of their involvement in DBT.

Who it is not for:

Patients not in DBT.

How can it be accessed:

In NHSH, the DBT program is a specialist service. Referrals are taken from secondary and specialist mental health services. The PDS encourages contact to discuss possible referrals. Patients cannot be referred for DBT-PE itself (as opposed to referring for DBT) as it represents a treatment strategy within DBT rather than a standalone treatment in its own right. All patients who are referred for DBT will receive a trauma assessment and DBT-PE will be offered if appropriate.

Eye movement desensitisation and reprocessing (EMDR)

What is it:

EMDR is a psychological treatment which has been demonstrated by several metaanalyses to be effective in the treatment of post-traumatic stress disorder (PTSD). It is recommended as a first line treatment for PTSD by NICE.

The treatment involves visualisation of traumatic events while experiencing auditory, visual or tactile bilateral stimulation. It is not a treatment specifically for people with personality disorder but was developed for people who experience PTSD. EMDR is listed here given the substantial proportion of people with personality disorder who also meet criteria for PTSD. EMDR represents a Phase 2 treatment.

Who is it for:

Individuals with PTSD who are sufficiently stable.

Who it is not for:

Individuals who are not sufficiently stable, especially those who use harmful behaviours to regulate emotional distress.

How can it be accessed:

Refer via Community Mental Health Team single point of referral. Direct discussion with the person who provides EMDR in the sector might be helpful to facilitate integration of Phase 1 with Phase 2 work.

Trauma Focused Cognitive Behavioural Therapy (tfCBT)

What is it:

tfCBT is a form of CBT which has been demonstrated by several meta-analyses to be effective in the treatment of post-traumatic stress disorder (PTSD). It is recommended as a first line treatment for PTSD by NICE. tfCBT represents a Phase 2 treatment. The treatment usually involves imaginal exposure to traumatic memories and real life exposure to avoided situations, together with cognitive restructuring. These procedures- can involve narrating the story of the traumatic events within session and listening to recordings of the story between sessions; actively exposing oneself to avoided and feared situations; and challenging unhelpful thoughts which are helping maintain patterns of avoidance. It is not a treatment specifically for people with personality disorder but is listed here given the substantial proportion of people with personality disorder who also meet criteria for PTSD.

Who is it for:

Individuals with PTSD who are sufficiently stable.

Who it is not for:

Individuals who are not sufficiently stable, especially those who use harmful behaviours to regulate emotional distress.

How can it be accessed:

Refer via Community Mental Health Team single point of referral. Direct discussion with the person who provides tfCBT in the sector might be helpful to facilitate integration of Phase 1 with Phase 2 work.