The Connection and Treatment of Comorbid NSSI, PTSD, and BPD
How a recently developed therapy seeks to better treatment outcomes among the three
*work regards NSSI (self-harm), suicidality, and PTSD*
The basis for this article was a paper I wrote in my senior Psychology capstone course, Psychology of Trauma. In this class, we had to pick a topic related to trauma and research it throughout the semester and ultimately write a research paper. Being a psychological interest of mine, I quickly chose to research nonsuicidal self-injury (NSSI) and eventually landed on researching its connection with posttraumatic stress disorder (PTSD).
While research on this connection is not the most prominent, I found there was extensive literature on the matter and a real interest concerned with the intersection of NSSI, PTSD, and borderline personality disorder (BPD). The main research used in this paper concerned the connection between PTSD symptom clusters and reasons for NSSI, treatment outcomes for people with NSSI, PTSD, and BPD, and a new treatment for those with such comorbidities.
Before digging into the research, I want to outline the terms and disorders mentioned above.
- NSSI: an act of damaging one’s own body without suicidal intent
- Deliberate Self-Harm: includes NSSI plus acts of damaging one’s body with suicidal intent
- PTSD: a disorder that is characterized by experiencing a traumatic event (or being repeatedly exposed second-hand to traumatic events) and then meeting the criteria of symptoms according to the DSM-5
- BPD: a personality disorder typified by varying moods, behavior, and a sense of self
I first wanted to see explore the relationship between PSTD and NSSI. This led me to an academic paper in 2020 by Ennis and authors. In the said paper, the authors explored whether PTSD symptom clusters in the DSM-5 (the standard psychological diagnostic manual) were associated with certain functions (or reasons) for NSSI.
The PTSD symptom clusters in the most recent DSM update are intrusion, avoidance of reminders of the trauma, negative alterations in cognitions and mood (NACM), and alterations in arousal. To be diagnosed with PTSD, a person must experience at least one symptom in each cluster.
Regarding NSSI, the study utilized intrapersonal and social functions, as prior research indicates these are the main reasons for NSSI. As to the intrapersonal function, a person may use NSSI to take their mind off the emotions they are feeling or simply to feel something when they are struggling to feel emotions (a symptom of depression, which is heavily comorbid with NSSI).
The social function encompasses ways in which a person may use NSSI to affect their social interactions. For instance, they may use it to give themselves a reason to not attend an event. While these functions do not reflect all possible reasons for NSSI, they do encompass a large majority of reasons.
The authors hypothesized the intrapersonal function of NSSI would be positively associated with the PTSD symptom clusters of intrusion and NACM, while the social function of NSSI would be associated with the PTSD symptom cluster of avoidance. To measure these hypotheses the authors completed a study with 81 college students (largely white females).
They discovered each PTSD symptom cluster was correlated with each NSSI function. Then, when using advanced statistical analysis, they discovered a path from the NACM PTSD symptom cluster to the intrapersonal function of NSSI and a path from avoidance of reminders of trauma to the social NSSI function. Thus, while correlations did exist between all clusters and functions, when statistically controlled, the paths verified two of the authors’ hypotheses.
The results from this study were statistically significant, but they also contain noteworthy clinical implications that may have a large impact on people’s lives. Firstly, people with PTSD should be assessed for NSSI due to the prevalence of comorbid PTSD and NSSI as well as the existence of paths from PTSD symptom clusters to functions of NSSI. NSSI is often a private part of a person’s life they are not keen to share.
Thus, a person may keep their NSSI private, even while seeking treatment for PTSD. By assessing for the presence of NSSI in PTSD patients, a patient may receive even better psychological treatment. Additionally, in the cases of comorbid PTSD and NSSI, working on treating a person’s certain PTSD symptoms may help to reduce their NSSI, particularly if their PTSD symptom is in a cluster that correlates to a function of NSSI.
After exploring the association of NSSI and PTSD, I began searching for treatment outcomes of patients with the two. This led me to a paper by Barnicot and authors which researched treatment outcomes of comorbid PTSD and BPD patients with NSSI. Specifically, this study explored whether comorbid BPD and PTSD resulted in poorer treatment outcomes with standard BPD psychotherapies.
While NSSI is a diagnostic symptom of BPD, research further indicates that comorbid BPD and PTSD are associated with more frequent self-harm and greater psychopathology. With this knowledge, Barnicot and authors hypothesized comorbid BPD and PTSD as well as more severe PTSD and less improvement in PTSD would be associated with more frequent self-harm and greater BPD severity while in treatment. Additionally, they mediated emotion dysregulation would mediate treatment outcomes in those with BPD and PTSD.
This study was completed by following 90 participants (largely white females) throughout their course of BPD treatment. Of these participants, 90% had self-harmed in the past year and 67 met the criteria for PTSD. Numerous significant results were generated with the study.
Firstly, those with comorbid PTSD and BPD were more likely to have self-harmed in the past year and to meet the diagnostic criteria of major depressive disorder. Then, initial PTSD severity was positively correlated with higher self-harm rates. Further, less improvement in PTSD by one year of treatment was associated with higher odds of recent self-harm. Lastly, emotion dysregulation mediated these last two results.
These results are quite noteworthy. While the relationship between NSSI and BPD has been well-established, PTSD’s connection with the two is less established. As indicated by the first study, Barnicot’s study indicates PTSD is correlated with self-harm rates. Then, it indicated that more severe PTSD and a lack of improvement in PTSD affect BPD treatment outcomes.
Additionally, this was the first study to show emotion dysregulation mediates the effects of PTSD on NSSI and BPD. One of the hallmark symptoms of BPD is mood swings in which people may struggle to regulate their emotions. Thus, Barnicot indicates that emotion dysregulation affects PTSD’s impact in comorbid BPD and NSSI. Lastly, and clinically, this study indicates some of the difficulties involved in treating patients with comorbid PTSD, BPD, and NSSI.
After learning of the difficulty in treating comorbid PTSD, BPD, and NSSI, I began researching a new psychotherapy developed by Dr. Melanie Harned designed to treat such patients. This psychotherapy is dialectical behavioral therapy (DBT) with the DBT prolonged exposure protocol (DBT + DBT PE).
DBT was developed by Dr. Marsha Linehan and is the standard treatment for suicidal patients with BPD and was used in the above study by Barnicot. Dr. Harned’s treatment expands upon DBT by adding the prolonged exposure protocol, which is a PTSD treatment. Thus, Dr. Harned’s treatment was developed for patients with comorbid PTSD, BPD, NSSI, and suicidality.
In 2014, Harned and authors completed a randomized control trial of their novel treatment to explore its acceptability, safety, and treatment outcomes. Additionally, they sought to compare DBT + DBT PE to standard DBT among patients with comorbid PTSD and BPD. They did not provide a hypothesis; however, they did note that many PTSD studies omit participants with recent NSSI or suicidality and that PTSD remission rates in comorbid PTSD and BPD patients are low for standard DBT.
To complete their randomized trial, 26 largely white women with comorbid PTSD, BPD, and recent deliberate self-harm were randomly treated with standard DBT or the novel DBT + DBT PE. Significant results were generated from this trial. Firstly, suicidal and self-harm urges remained more stable throughout treatment in the sole DBT group. Then, larger effect sizes were found in the frequency of suicide attempts pre to post-treatment in the DBT + DBT PE group than the DBT group.
Next, while both groups had large effect sizes on the reduction of PTSD, three months after treatment, no patients in the sole DBT group were in PTSD remission, while 60% of those who completed the DBT + DBT PE treatment group were in remission and even 50% of those who did not complete the DBT + DBT PE treatment were in remission.
Further, those who completed the DBT + DBT PE treatment had the largest improvement in PTSD severity. Finally, those in the DBT + DBT PE group had decreases in anxiety and increases in psychological well-being, while those in the sole DBT group did not.
These results were noteworthy as they show DBT + DBT PE to be a safe and efficacious treatment for those with comorbid self-harm, PTSD, and BPD. Additionally, it was more effective than solely DBT in this population. Furthering the reputation of this novel treatment, in 2018 Harned further explored the outcomes of the 2014 trial and another trial.
This additional research showed that no measured symptoms were worsened throughout therapy, while those in the DBT + DBT PE groups experienced higher psychological well-being compared to the sole DBT groups. Additionally, this study showed that dissociation was significantly reduced in the DBT + DBT PE groups.
In sum, research shows the connection between NSSI and PTSD, particularly as it relates to BPD. Further, the complexity of such comorbidities has been documented. Ennis and authors showed PTSD symptom clusters are associated with certain functions of NSSI. Then, Barnicot and authors showed the complexities in treatment outcomes of patients with comorbid PTSD, BPD, and NSSI.
Lastly, Harned’s novel treatment was developed to treat such patients and its efficacy has been demonstrated as well as its advantages over sole DBT among such comorbid patients. While much research has been done, more research needs to be completed to better understand the development, treatment, and relationship among those with comorbid PTSD, BPD, and NSSI. Further research will serve to better clinical interventions among such patients and perhaps serve to help those who are struggling.
If you are experiencing issues related to the disorders mentioned in this article or any other mental health issue, the SAMSHA national hotline can be reached anytime at 1–800–4357(HELP). Additionally, in times of crisis, the Crisis Text Line can be reached any time by texting HOME to 741741.
