Treatment of Patients with Borderline Personality Disorder and Comorbid Posttraumatic Stress Disorder Using Narrative Exposure Therapy: A Feasibility Study

comorbid PTSD. Within an open trial, 10 women with BPD and comorbid PTSD were treated at the Center of Integrative Psychiatry in Kiel using NET. NET is a standardized, controlled short-term intervention which is based on the core assumption that a maladaptive traumarelated network of memory representations has resulted from multiple adverse and fearful experiences [9] . NET is now considered to be a comparatively well-tested therapy approach for patients who have survived different types of trauma, ranging from domestic violence and emotional neglect to organized violence [10, 11] . It aims primarily at reducing PTSD symptoms by changing associative memory related to the traumatic experiences through recall of the event and exposure, assigning each event the respective time and place at which it had been experienced. This promotes a coherent autobiographical memory associated with the sensory, affective and cognitive cues of the event [12] , and in addition has nondissociative effects [6] . After detailed psychoeducation, the patient is encouraged to narrate the events of his/her life in a chronological order, from birth to the present day, by using a ‘lifeline’ (symbolized by a line or rope and flowers representing well-remembered positive, and stones representing the traumatic events). In a client-friendly therapeutic environment, it is possible to link the various components (thoughts, emotions, body reactions, contextual information) and integrate them into the patient’s biography. For a more detailed explanation of the basic theoretical assumptions and the method, we refer to Neuner et al. [12] and Schauer et al. [13] . During the period between January 2009 and May 2010, 12 women presenting with BPD and comorbid PTSD were recruited from our clinic. After psychological diagnoses considering the inand exclusion criteria, of those informed about the study, no one refused; 2 women dropped out for practical reasons. Six women underwent therapy in a hospital, 3 on an outpatient basis, and 1 patient started treatment in hospital but then continued her therapy as an outpatient. Whenever possible, the medication administered to the patients during treatment was kept stabile. On average, the women were 33 years old (range: 19–45 years), and all had already received some form of psychoand pharmacotherapy, although none had received trauma-focused treatment before. Prior to treatment, a diagnosis was reached by conducting a standardized and structured clinical interview based on the Mini-International Neuropsychiatric Interview [14] and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders [15] . After the initial diagnosis, the Posttraumatic Stress Diagnostic Scale (PDS) was applied as an interview [16, 17] . This instrument records PTSD symptoms in accordance with the DSM-IV. Depression symptoms were assessed by clinician ratings using the Hamilton Depression Rating Scale (HAM-D) [18, 19] , as well as by means of the Hopkins Symptom Checklist 25 (HSCL25) [20–22] . The severity of BPD symptoms was evaluated by selfAn increasing number of women (0.8–2% of the general public) seem to be affected by borderline personality disorder (BPD) [1] . Whereas BPD is already characterized by a high rate of psychiatric problems, current evaluations indicate that the frequency of comorbid posttraumatic stress disorder (PTSD) ranges between 33 and 61% among patients with BPD [2–4] . Clinicians have frequently noted that a combination of BPD and PTSD leads to mutual amplification of symptoms and thus to most severe impairment of functioning on all levels. A main symptom of BPD concerns sudden, intensive and aversive tension that is difficult for these patients to endure and to regulate [5, 6] . When there is comorbid PTSD, BPD symptoms are potentially intensified by the related anxiety, hyperarousal and intrusions, triggering sudden, uncontrollable and incomprehensible attacks of tension and fear. This prompts a vicious circle of uncontrollable swings in tension and dysfunctional behavioral patterns (e.g. self-inflicted pain and injuries), which in turn makes it impossible to modify maladaptive core beliefs. It has frequently been assumed that patients being treated for BPD can only start to confront traumatic experiences once they have been sufficiently stabilized [3] . Neuner [7] carried out a critical examination of the processes involved in stabilization and confrontation and concluded that little evidence suggests that a stabilization phase prior to trauma exposure would be useful. A suitable trauma-focused therapy for patients with BPD and comorbid PTSD seems essential in order to reduce the burden of symptoms and to help patients understand and integrate the traumatic experiences into their lives. So far, there have been few attempts to treat both BPD and PTSD simultaneously [8] . The present approach sought to test the feasibility of narrative exposure therapy (NET), a trauma-focused therapy suitable for both inand outpatient settings which can be taught to clinically experienced therapists in a short-term training program and implemented in a comprehensive treatment for BPD patients with Received: February 9, 2011 Accepted after revision: May 22, 2011 Published online: November 25, 2011