Psychology paper

Journal of Traumatic Stress, Vol. 23, No. 4, August 2010, pp. 421–429 ( C 2010) Dialectical Behavior Therapy as a Precursor to PTSD Treatment for Suicidal and/or Self-Injuring Women With Borderline Personality Disorder Melanie S. Harned, Saﬁa C. Jackson, Katherine A. Comtois, and Marsha M. Linehan University of Washington This study examined the efﬁcacy of dialectical behavior therapy (DBT) in reducing behaviors commonly used as exclusion criteria for posttraumatic stress disorder (PTSD) treatment. The sample included 51 suicidal and/or self-injuring women with borderline personality disorder (BPD), 26 (51%) of whom met criteria for PTSD. BPD clients with and without PTSD were equally likely to eliminate the exclusionary behaviors during 1 year of DBT. By posttreatment, 50–68% of the BPD clients with PTSD would have been suitable candidates for PTSD treatment. Borderline personality disorder clients with PTSD who began treatment with a greater number of recent suicide attempts and more severe PTSD were signiﬁcantly less likely to become eligible for PTSD treatment.

Individuals with posttraumatic stress disorder (PTSD) have been found to be at heightened risk for both suicidal behavior and nonsuicidal self-injury. The U.S. National Comorbidity Sur- vey found that individuals with PTSD were six times more likely to attempt suicide and ﬁve times more likely to report suicidal ideation than those without PTSD (Kessler, 2000). In a large Eu- ropean epidemiological study, individuals with PTSD reported the highest lifetime rate of suicidal ideation (32.9%) and the third highest lifetime rate of suicide attempts (10.7%) compared to individuals with other mental disorders (Bernal et al., 2007).

Among treatment-seeking PTSD samples, 50–60% report a his- tory of nonsuicidal self-injury (e.g., Cloitre, Koenen, Cohen, & Han 2002; Zlotnick, Mattia, & Zimmerman, 1999).

Despite the prevalence of suicidal behavior and nonsuicidal self-injury among individuals with PTSD, it is common prac- tice to exclude individuals with these co-occurring behaviors from PTSD treatments (Bradley, Greene, Russ, Dutra, & Westen, 2005; Melanie S. Harned, Saﬁa C. Jackson, Department of Psychology, University of Washington; Katherine A. Comtois, Department of Psychiatry, University of Washington; Marsha M.

Linehan, Department of Psychology, University of Washington.

Portions of this paper were presented at the 42nd Annual Convention of the Association for Behavioral and Cognitive Therapies, November 2008, Orlando, FL. This study was supported by grants MH34486 and MH01593 from the National Institute of Mental Health to the last author. We thank the clients, therapists, assessors, and staff at the Behavioral Research and Therapy Clinics, without whom this research would not have been possible.

Correspondence concerning this article should be addressed to: Melanie Harned, Behavioral Research and Therapy Clinics, Department of Psychology, 3935 University Way NE, University of Washington, Seattle, Washington 98105. E-mail: [email protected].

C 2010 International Society for Traumatic Stress Studies. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.20553 Stirman, 2008). Indeed, the recently updated PTSD practice guidelines from the International Society for Traumatic Stress Studies recommend that, “If signiﬁcant suicidality is present, it must be addressed before any other treatment is initiated” (Foa, Keane, Friedman, & Cohen, 2009, p. 9). While similar recommendations are made in other PTSD practice guidelines (e.g., Forbes et al., 2007; U.S. Department of Veterans Affairs/ Department of Defense, 2004), no research to date has examined how to effectively treat and stabilize suicidal behaviors and nonsui- cidal self-injury among individuals with PTSD so that they may be eligible for a targeted PTSD treatment.

Dialectical behavior therapy (DBT; Linehan, 1993a, 1993b) is the most empirically supported treatment available for suicidal behaviors and nonsuicidal self-injury (see Lynch, Trost, Salsman, & Linehan, 2007 for a review), particularly among individuals who meet criteria for borderline personality disorder (BPD), a di- agnosis with a high rate of PTSD comorbidity (e.g., Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004; Zimmerman & Mattia, 1999). Consequently, in an effort to increase the tolerabil- ity and efﬁcacy of PTSD treatment among BPD and other more severe clients, several treatments have recently been developed that use standard DBT (Harned & Linehan, 2008) or modiﬁed ver- sions of DBT techniques (Becker & Zayfert, 2001; Cloitre et al., 2002; Zayfert & Becker, 2000; Zayfert et al., 2005) prior to or during PTSD treatment. Despite this use of DBT as a priming in- tervention prior to initiating PTSD treatment, no study has specif- ically evaluated how effective DBT is at helping suicidal and/or self-injuring PTSD clients stabilize these and other problematic behaviors so that they might be suitable for PTSD treatment.

421 422Harned et al.

The primary aim of the present study is to examine the efﬁcacy of DBT in reducing behaviors commonly used as exclusion crite- ria for PTSD treatment among a sample of recent and chronically suicidal and/or self-injuring women with PTSD and BPD. Exclu- sion criteria for PTSD treatment were operationalized according to the deﬁnitions provided in the Prolonged Exposure manual (PE; Foa, Hembree, & Rosenbaum, 2007) and include (a) im- minent threat of suicidal or homicidal behavior, (b) serious self- injurious behavior in the past 3 months, (c) current psychosis, (d) current high risk of being assaulted (e.g., living with domestic violence), and (e) lack of clear memory or insufﬁcient memory of traumatic event(s) (Foa et al., 2007). In addition, the PE man- ual suggests that several additional problems, such as substance dependence and severe dissociation, need to be considered on a case-by-case basis in determining whether to initiate PTSD treat- ment (Foa et al., 2007). PE was selected because exposure therapy has received the most empirical support as a treatment for PTSD (Foa et al., 2009; Institute of Medicine, 2007), PE is the most widely studied manualized exposure treatment, and the exclusion criteria for PE are comparable to those used in other PTSD treat- ments (e.g., Cloitre et al., 2002; McDonagh et al., 2005; Resick et al., 2008).

A secondary aim was to determine whether BPD women with and without PTSD were equally likely to eliminate these exclusion- ary behaviors during DBT. Co-occurring PTSD is associated with greater impairment among individuals with BPD (e.g., Bolton, Mueser, & Rosenberg, 2006; Harned, Rizvi, & Linehan, in press) and the presence of PTSD predicts a lower likelihood of remit- ting from BPD across 6 and 10 years of naturalistic follow-up (Zanarini et al., 2004; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006). Thus, it is possible that BPD clients with PTSD may be less likely to achieve control over these exclusionary behaviors during DBT. If true, this could indicate a need to modify DBT to improve its ability to function as a priming intervention for PTSD treatment in this population.

Finally, we sought to determine whether a variety of baseline characteristics would differentiate between BPD+PTSD clients who did and did not become eligible for PTSD treatment by posttreatment. Speciﬁcally, we hypothesized that, among BPD clients with PTSD, those who were more severe at baseline on continuous measures of each of the exclusionary behaviors, PTSD severity, global functioning, and number of comorbid Axis I disorders, would be less likely to become eligible for PTSD treatment by posttreatment. Finally, given research indi- cating that childhood trauma is associated with greater impair- ment (e.g., suicidal behavior, dissociation) than adult trauma (Cloitre, Scarvalone, & Difede, 1997; Zlotnick et al., 1996), we hypothesized that BPD clients with PTSD related to childhood trauma would be less likely to eliminate the exclusionary behav- iors by posttreatment than those whose index trauma occurred in adulthood. METHOD Participants Participants were drawn from a sample of BPD women who par- ticipated in a randomized controlled trial, were randomized to the DBT condition, and exhibited at least one required exclusion cri- terion for PTSD treatment at baseline (n=51; Linehan, Comtois, Murray, et al., 2006). Inclusion criteria in this study included (a) met criteria for BPD, (b) age 18–45, (c) female, and (d) at least two suicide attempts and/or nonsuicidal self-injuries in the past 5 years, with at least one act occurring in the 8-week period prior to entering the study. Subjects were excluded if they met criteria for a psychotic disorder, mental retardation, or bipolar disorder, had a seizure disorder requiring medication, were mandated to treat- ment, or required primary treatment for another debilitating con- dition. All participants read and signed an informed consent form and all protocols were approved by the University of Washington Human Subjects Division.

Measures The Structured Clinical Interview for Axis II DSM-IV (SCID- II; First, Spitzer, Gibbon, & Williams, 1995a) was used to assess current BPD at pretreatment. The International Personality Dis- orders Examination (Loranger, 1995) is an interview that was used to conﬁrm the SCID-II BPD diagnosis and assess all other Axis II diagnoses at pretreatment. The International Personality Disorders Examination has been shown to have good interrater reliability and temporal stability (Loranger et al., 1994). The Structured Clinical Interview for DSM-IV, Axis I (SCID-I; First, Spitzer, Gibbon, & Williams, 1995b) was used to assess current Axis I diagnoses at pretreatment. During administration of the PTSD module of the SCID-I, participants were asked to describe the most distressing trauma they experienced (i.e., the index trauma) and the age at which it occurred. Severity of the PTSD diagnosis was rated by the interviewer as 1=mild,2=moderate,3=severe.

Four PE exclusion criteria were assessed in the present study:

(1) imminent threat of suicidal behavior, (2) recent self-injury, (3) current substance dependence disorder, and (4) severe dissocia- tion. For each PE exclusion criterion, we developed an operational deﬁnition that is provided in Table 1. Two deﬁnitions of readi- ness for PTSD treatment were used. Composite 1 includes only those behaviors recommended as exclusion criteria for all clients in the PE manual (i.e., 1 and 2 above), and Composite 2 includes the deﬁnite as well as the possible (to be determined on a case-by-case basis) exclusion criteria recommended in the PE manual (i.e., 1, 2, 3, and 4 above).

The Suicidal Behaviors Questionnaire (Linehan, 1981) is a 34-item self-report measure of suicidal behaviors that has been shown to have high internal reliability and good concurrent validity Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. DBTasaPrecursortoPTSDTreatment423 Ta b l e 1 .Operational Deﬁnitions of the Exclusion Criteria for PTSD Treatment Exclusion criteria Operational deﬁnition Measures used Composite(s) 1. Imminent threat of suicidal behavior Current suicidal ideation a,AND Intent to commit suicide in the next 4 weeks b,AND Current suicide plan c SBQ 1 and 2 2. Recent self-injurious behavior (past 4 months) Suicide attempt, OR Nonsuicidal self-injury that had more than a mild effect on the person’s physical condition d SASII 1 and 2 3. Substance dependence Current substance dependence disorderLIFE/SCID-I 2 4. Severe dissociation Current dissociative disorder e DES-T 2 Note.PTSD=posttraumatic stress disorder; SBQ=Suicidal Behaviors Questionnaire; SASII=Suicide Attempt Self-Injury Interview; LIFE=Longitudinal Interview Follow-up Evaluation; SCID-I=Structured Clinical Interview for DSM-IV, Axis I; DES-T=Dissociative Experiences Scale–Taxon.

aDeﬁned as a score of 2 (sometimes) or higher on the SBQ item assessing the frequency of suicidal ideation in the past 4 weeks. bDeﬁned as a score of 2 (some chance)or higher on the SBQ item assessing the likelihood of attempting suicide in the next 4 weeks. cDeﬁned as the presence of either a “vague” or “deﬁnite” suicide plan. dOn the SASII, “mild effect” is deﬁned as “Death is highly improbable; could only occur due to secondary complications or very unusual circumstance.” Examples include superﬁcial lacerations without tendon, nerve, or vessel damage and not requiring sutures; ﬁrst-degree burn; nauseous. This cutoff for determining which typesof nonsuicidal self-injury acts to exclude was selected after consulting with Dr. Edna Foa, who indicated that Prolonged Exposure typically only excludes individuals who engage in cutting that is deeper than superﬁcial scratches (Foa, personal communication). eDeﬁned as a score greater than 20 on the DES-T. (Addis & Linehan, 1989). In this study, we used three Suicidal Behaviors Questionnaire items (α=.75) to assess imminent threat of suicidal behavior: (a) suicidal ideation in the past 4 weeks (0= notatallto 4=very often), (b) likelihood of attempting suicide in the next 4 weeks (0=no chance at allto 4=very likely), and (3) the presence of a suicide plan (0=no,1=yes, a vague plan, 2=yes, a deﬁnite plan).

The Suicide Attempt Self Injury Interview (Linehan, Comtois, Brown, Heard, & Wagner, 2006) is an interview that was used to measure the frequency, suicide intent, and medical severity of suicidal behavior and nonsuicidal self-injury. The Suicide Attempt Self Injury Interview has been found to have very good interrater reliability and adequate validity (Linehan, Comtois, Brown, et al., 2006). In the present study, we used items assessing (a) the inci- dence and recency of suicide attempts and nonsuicidal self-injury, and (b) the effect of nonsuicidal self-injury on the individual’s physical condition (0=no effectto 7=lethal effect, death occurred).

The Longitudinal Interval Follow-Up Evaluation (Keller et al., 1987) assessed the diagnostic status of substance dependence dis- orders and PTSD at each outcome assessment point. The Longitu- dinal Interval Follow-Up Evaluation is a semistructured interview that uses a timeline follow-back procedure to retrospectively as- sign weekly psychological status ratings for each Axis I disorder:

1=none,2=moderate,and3=severe. Consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR; American Psychiatric Asso- ciation, 2000) remission criteria for substance dependence disor- ders, we deﬁned early full remission as psychological status rat- ing=1 for at least 4 weeks but less than 52 weeks. For PTSD,we followed conventions for the longitudinal interval follow-up evaluation and deﬁned “full remission” as a period of at least 8 consecutive weeks with minimal or no symptoms (psychological status rating=1). High interviewer-observer reliability has been shown for the change points in diagnostic criteria as well as for the level of psychopathology (Keller et al., 1987).

The Dissociative Experiences Scale-Taxon (DES-T; Waller & Ross, 1997) is an 8-item self-report measure of pathological dis- sociation that was empirically derived from the larger Dissociative Experiences Scale (Bernstein & Putnam, 1986). Items are rated from 0 to 100 with scores reﬂecting the percentage of time that each dissociative experience applies to the individual’s life. The DES-T has been shown to have a high probability of success- fully predicting membership in a pathological dissociation taxon (Waller & Ross, 1997). A cutoff score of 20 on the DES-T has been recommended to identify clients with dissociative disorders and predictions based on this cut-off have been shown to have high concurrent validity (Ross, Duffy, & Ellason, 2002). Procedure All participants received standard DBT (Linehan, 1993a, 1993b), a cognitive-behavioral treatment program developed to treat a va- riety of severe and out-of-control behaviors among BPD clients.

DBT targets, in hierarchical order, life-threatening behaviors (e.g., suicidal behavior and nonsuicidal self-injury), behaviors that inter- fere with treatment delivery (e.g., noncompliance, therapist/client relationship difﬁculties), and severe quality of life interfering be- haviors (e.g., severe Axis I disorders). Clients in DBT received Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 424Harned et al.

(a) weekly individual psychotherapy (1 hour per week), (b) group skills training (2.5 hours per week), and (c) phone consultation (as needed). Additionally, DBT therapists attended a weekly therapist consultation team meeting.

Assessments occurred at pretreatment and at 4-month intervals through the 1-year treatment. Assessments were conducted by clinical assessors who were blind to treatment condition and had been trained on interview measures by the instrument developers or an approved trainer and then evaluated for reliability (kappa or intraclass correlations for all diagnostic ratings ranged between .74–1.0; Linehan, Comtois, Murray, et al., 2006).

Data Analysis Descriptive data on the incidence of each exclusion criterion for PTSD treatment and the overall composites were computed for each time-point separately for BPD clients with and without PTSD. Using the intent-to-treat sample, binary hierarchical linear models (HLM) were computed to analyze the efﬁcacy of DBT in decreasing each exclusion criterion as well as the two overall com- posites across time. Predictors in the analyses were PTSD status at pretreatment (0=no PTSD,1=PTSD), time (0=pretreatment, 1=4month,2=8month,3=12 month), and the interaction of the two. In addition, contrast statements computed the rates of within-group change. All models used all available data. Finally, ttests (with Cohen’sdeffect sizes) were calculated to compare the baseline characteristics of BPD+PTSD clients who did and did not eliminate all exclusionary behaviors by 12 months (i.e., posttreatment).

RESULTS Twenty-six women (51%) met criteria for co-occurring PTSD. The sample demographics and rates of current Axis I and II diagnoses at pretreatment are provided in Table 2 by PTSD status and for the sample as a whole. BPD clients with PTSD met criteria for more current Axis I disorders (including PTSD) than those without PTSD,t(49)=2.33,p<.05. No other demographic or diagnostic differences were found. Table 3 summarizes the type and age of onset of the index trauma as well as PTSD severity among the BPD clients with PTSD.

The prevalence rates of each individual exclusion criterion as well as the two composite measures at each assessment period are provided in Table 4 for descriptive purposes. The results of binary HLM models are presented in Table 5 and indicate that, during the treatment year, the number of clients eligible for PTSD treat- ment using the two composite deﬁnitions signiﬁcantly increased and this did not differ based on PTSD status. When the indi- vidual exclusion criteria were examined separately, both imminent suicide risk and recent self-injury signiﬁcantly decreased across time and this did not differ based on PTSD status. In contrast, neither substance dependence nor severe dissociation signiﬁcantlydecreased across time among the sample as a whole. However, the within-group slopes indicated that BPD+PTSD clients showed a signiﬁcant decrease in both substance dependence and severe dis- sociation across time whereas BPD clients without PTSD did not.

In addition, among clients who became eligible for PTSD treat- ment at each assessment point, the majority (80–100%) continued to meet criteria for PTSD (see Table 4).

At 12 months (i.e., posttreatment,n=22 BPD+PTSD clients with valid data 1), 7 clients (31.8%) still met at least one deﬁnite exclusion criterion (i.e., Composite 1) and 11 clients (50.0%) still met at least one deﬁnite or possible exclusion criterion (i.e., Com- posite 2). We hypothesized that clients who remained ineligible for PTSD treatment at posttreatment would be more severe on a variety of baseline characteristics and would be more likely to re- port a childhood index trauma than those who did become eligible for PTSD treatment. For Composite 1, clients who did not elimi- nate the exclusionary behaviors by posttreatment had signiﬁcantly more severe PTSD at baseline and had more suicide attempts in the 4 months prior to starting treatment (see Table 6). In contrast to hypotheses, the remaining baseline characteristics did not dis- tinguish between clients who did and did not become eligible for PTSD treatment, including whether the index trauma occurred in childhood or adulthood. Moreover, no baseline characteristics signiﬁcantly discriminated between clients who did and did not become eligible for PTSD treatment by posttreatment according to Composite 2. DISCUSSION The primary goal of the present study was to examine whether, when, and which suicidal and/or self-injuring BPD clients with PTSD were able to eliminate behaviors commonly used as exclu- sion criteria for PTSD treatment after 1 year of DBT. In addition, we sought to determine whether DBT’s efﬁcacy at eliminating these behaviors differed for BPD clients with and without PTSD.

To this end, we examined the prevalence of key exclusion crite- ria for PTSD treatment among a sample of suicidal and/or self- injuring outpatients with BPD who received 1 year of DBT, half of whom (n=25, 51%) met criteria for current PTSD. At pre- treatment, all of these BPD clients exhibited at least one exclusion criterion for PTSD treatment.

The ﬁndings indicate that DBT signiﬁcantly decreases exclu- sionary behaviors for PTSD treatment among suicidal and/or self-injuring clients with BPD and PTSD. Between pre- and posttreatment, both imminent suicide risk (28.0% vs. 0.0%) and current substance dependence (19.2% vs. 0.0%) were com- pletely eliminated in this sample. The percentage of BPD+PTSD clients exhibiting recent self-injury (96.2% vs. 29.2%) and severe 1Reasons for missing data at the 12-month assessment included: death due to medical causes (n=1), assessment drop-out (n=1), unreachable (n=1), and refused to respond to self-report questionnaires (n=1). Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. DBTasaPrecursortoPTSDTreatment425 Ta b l e 2 .Pretreatment Demographic and Diagnostic Data for BPD Clients With and Without PTSD BPD+PTSD (n=26) BPD (n=25) Total sample (n=51) Age,M(SD) 28.2 (7.4) 30.3 (7.1) 29.2 (7.3) Race (%) White 84.0 92.0 88.0 African American 4.0 4.0 4.0 Asian American 4.0 0.0 2.0 Native American or Alaskan Native 0.0 4.0 2.0 Other 8.0 0.0 4.0 Single, divorced, or separated (%) 96.2 80.0 88.2 Education (%) $30,000 7.7 12.5 10.0 Current Axis I psychiatric diagnoses (%) Major depressive disorder 65.4 76.0 70.6 Panic disorder 42.3 40.0 41.2 Social anxiety disorder 15.4 12.0 13.7 Obsessive compulsive disorder 15.4 16.0 15.7 Generalized anxiety disorder 11.5 4.0 7.8 Speciﬁc phobia 15.4 16.0 15.7 Substance abuse disorder 3.8 4.0 3.9 Substance dependence disorder 19.2 20.0 19.6 Any eating disorder 15.4 32.0 23.5 Current Axis II psychiatric diagnoses (%) Antisocial personality disorder 11.5 12.0 11.8 Paranoid personality disorder 3.8 0.0 2.0 Avoidant personality disorder 15.4 20.0 17.6 Obsessive compulsive personality disorder 7.7 8.0 7.8 Histrionic personality disorder 3.8 0.0 2.0 Dependent personality disorder 3.8 4.0 3.9 Schizoid personality disorder 0.0 0.0 2.0 Total number of current Axis I diagnosesM(SD) a∗ 3.2 (1.4) 2.4 (1.2) 2.8 (1.3) Total number of current Axis II diagnosesM(SD) b 1.5 (0.7) 1.4 (0.6) 1.4 (0.7) Note.BPD=borderline personality disorder; PTSD=posttraumatic stress disorder.aIncludes PTSD. bIncludes BPD. ∗The two groups differ atp<.05. dissociation (44.0% vs. 22.7%) also decreased signiﬁcantly from pre- to posttreatment. Taken together, 50 to 68% of these clients would have been appropriate candidates for PTSD treatment after 1yearofDBT.

The results also indicate that the presence of co-occurring PTSD does not attenuate DBT’s impact on these behaviors among BPD clients, suggesting that standard DBT is well-suited to addressthe needs of suicidal and/or self-injuring BPD+PTSD clients. In particular, BPD clients with PTSD were just as likely to eliminate imminent suicide risk, recent self-injury, and to become eligible for PTSD treatment according to both composite deﬁnitions as BPD clients without PTSD. Moreover, BPD+PTSD clients showed a signiﬁcant decrease in severe dissociation and substance depen- dence during DBT whereas BPD clients without PTSD did not. Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 426Harned et al.

Ta b l e 3 .Index Trauma Characteristics and Severity of PTSD Among BPD+PTSD Clients (n=23) % Type of index trauma Any childhood trauma (ages 0–12) 82.6 Childhood sexual abuse 43.5 Childhood physical abuse 21.7 Childhood sexual and physical abuse 4.3 Other childhood trauma 13.0 Any adult trauma (ages 18+) 17.4 Adult sexual assault 4.3 Adult physical assault 0.0 Motor vehicle accident 8.7 Other adult trauma 4.3 Severity of PTSD diagnosis Mild 11.8 Moderate 52.9 Severe 35.3 Note.Data are missing for 3 clients. The index trauma was deﬁned as the trauma reported to be most distressing by the client. No clients reported an index trauma that occurred during adolescence (ages 13–17). PTSD=posttraumatic stress disorder; BPD=borderline personality disorder. Ta b l e 4 .Rates of Individual Exclusion Criteria and Overall Composites at Each Assessment Point Pretreatment 4 Months 8 Months 12 Months BPD+PTSD BPD BPD+PTSD BPD BPD+PTSD BPD BPD+PTSD BPD (n=25-26) (n=25) (n=25-26) (n=23-25) (n=25-26) (n=23-25) (n=21-26) (n=24-25) n(%)n(%)n(%)n(%)n(%)n(%)n(%)n(%) Individual exclusion criteria Imminent risk of suicide 7 (28.0) 9 (36.0) 3 (12.0) 2 (8.7) 2 (8.0) 1 (4.3) 0 (0.0) 2 (8.0) Recent self-injurious 25 (96.2) 24 (96.0) 18 (69.2) 15 (60.0) 12 (48.0) 11 (44.0) 7 (29.2) 11 (44.0) behavior Severe dissociation 11 (44.0) 8 (32.0) 10 (38.5) 5 (20.8) 6 (24.0) 5 (21.7) 5 (22.7) 4 (16.0) Substance dependence 5 (19.2) 5 (20.0) 2 (7.7) 4 (16.0) 1 (3.8) 3 (12.0) 0 (0.0) 4 (16.7) Eligible for PTSD treatment Composite 1 0 (0.0) 0 (0.0) 7 (26.9) 10 (40.0) 12 (48.0) 13 (54.2) 15 (68.2) 14 (56.0) Remitted from PTSD – – 0 (0.0) – 1 (8.3) – 3 (20.0) – Composite 2 0 (0.0) 0 (0.0) 4 (15.4) 8 (32.0) 9 (36.0) 12 (50.0) 11 (50.0) 10 (41.7) Remitted from PTSD – – 0 (0.0) – 1 (11.1) – 2 (18.2) – Note.Then’s differed slightly at each assessment point due to missing data on some measures. Percentages are computed based on valid (nonmissing) data. Composite 1 includes (a) imminent suicide risk and (b) recent self-injurious behavior. Composite 2 includes (a) imminent suicide risk, (b) recent self-injurious behavior, (c) severe dissociation, and/or (d) substance dependence. PTSD=posttraumatic stress disorder; BPD=borderline personality disorder. These ﬁndings mirror results from previous studies indicating that the addition of BPD to PTSD does not signiﬁcantly alter the out- come of PTSD treatments (Clarke, Rizvi, & Resick, 2008; Feeny, Zoellner, & Foa, 2002) and suggest that the opposite may also be true. Namely, the presence of PTSD does not appear to inter- fere with, and may even improve, DBT treatment outcomes for individuals with BPD.

Among those BPD+PTSD clients who became eligible for PTSD treatment by posttreatment, the majority (80–82%) con- tinued to meet criteria for PTSD. These ﬁndings are consistent with research indicating that the rate of PTSD remission during 1 year of DBT and 1 year of follow-up is low (34.8%; Harned et al., 2008). This low remission rate is likely due to the fact that PTSD is typically not targeted during 1 year of standard DBT with suicidal and/or self-injuring clients. Instead, the treatment focuses on obtaining control over life-threatening behaviors and other forms of behavioral dyscontrol. The present data suggest, how- ever, that treating PTSD may be feasible during 1 year of DBT for those clients who are able to eliminate these exclusionary behaviors.

These ﬁndings point to the importance of adding a targeted PTSD treatment to DBT and recent treatment development efforts in this area have shown promising results (Harned & Linehan, 2008).

It is also important to note that, after 1 year of DBT, a signiﬁ- cant subgroup of BPD+PTSD clients (31.8 to 50.0% depending Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. DBTasaPrecursortoPTSDTreatment427 Ta b l e 5 .Results of Binary Hierarchical Linear Model Analyses PTSD effect Time effect PTSD×Time Effect Within-group slopes Coefﬁcient (SE) Coefﬁcient (SE) Coefﬁcient (SE) BPD+PTSD BPD Individual exclusion criteria Imminent risk of suicide a −0.08 (0.66)−0.88 (0.33) ∗∗ −0.15 (0.51)−1.03 ∗∗ −0.88 ∗∗ Recent self-injurious behavior 0.60 (0.67)−0.86 (0.26) ∗∗ −0.37 (0.39)−1.23 ∗∗∗ −0.86 ∗∗ Severe dissociation a 0.80 (0.74)−0.38 (0.26)−0.13 (0.35)−0.51 ∗ −0.38 Substance dependence a 0.38 (1.02)−0.22 (0.34)−1.20 (0.67)−1.42 ∗ −0.22 Composites Composite 1 0.86 (0.76)−0.96 (0.28) ∗∗ −0.44 (0.44)−1.40 ∗∗∗ −0.96 ∗∗∗ Composite 2 1.15 (0.84)−0.76 (0.28) ∗∗ −0.43 (0.44)−1.20 ∗∗∗ −0.76 ∗∗ Note.Unless otherwise indicated, all binary hierarchical linear models (HLM) included a random effect for slope. Composite 1 includes (a) imminent suicide risk and (b) recent self-injurious behavior. Composite 2 includes (a) imminent suicide risk, (b) recent self-injurious behavior, (c) severe dissociation, and/or (d) substance dependence.

PTSD=posttraumatic stress disorders; BPD=borderline personality disorder.

aBinary HLM model included a random effect for intercept.∗p<.05. ∗∗p<.01. ∗∗∗ p<.001. Ta b l e 6 .Baseline Characteristics of BPD Clients with PTSD Who Did and Did Not Become Eligible for PTSD Treatment by Posttreatment Composite 1 Composite 2 Eligible Not eligible Eligible Not eligible for PTSD for PTSD for PTSD for PTSD treatment treatment treatment treatment (n=15) (n=7) (n=11) (n=11) Baseline characteristicsMSDMSD t d MSDMSD t d Nonsuicidal self-injury acts, past 4 months a 2.6 2.2 2.1 1.8 1.83 0.25 2.7 0.5 1.0 0.8 2.05 2.55 Suicide attempts, past 4 months 0.2 0.4 1.4 1.9 2.44 ∗ 0.87 0.3 0.5 0.9 1.6 1.24 0.51 Dissociation severity 25.4 20.4 24.4 13.1 0.12 0.06 19.2 14.6 31.6 20.4 1.62 0.70 Drug/alcohol abstinent days, past 30 21.3 9.3 28.3 3.0 1.92 1.01 20.6 9.5 26.4 6.2 1.69 0.72 PTSD severity 1.9 0.8 2.6 0.5 2.19 ∗ 1.05 1.9 0.7 2.3 0.8 1.12 0.53 Timing of index trauma b 0.3 0.5 0.0 0.0 1.54 0.85 0.2 0.4 0.2 0.4 0.11 0.00 Current Axis I diagnoses 3.3 1.3 3.0 1.5 0.52 0.21 3.3 1.3 3.2 1.5 0.15 0.07 Global Assessment of Functioning score 43.0 5.1 37.1 9.1 1.95 0.80 42.2 5.3 40.1 8.5 0.69 0.30 Note.Composite 1 includes (a) imminent suicide risk and (b) recent self-injurious behavior. Composite 2 includes (a) imminent suicide risk, (b) recent self-injurious behavior, (c) severe dissociation, and/or (d) substance dependence. PTSD=posttraumatic stress disorder; BPD=borderline personality disorder.

aOnly includes non-suicidal self-injury acts that had more than a mild effect on the individual’s physical condition. bCoded as 0=childhood,1=adulthood. ∗p<.05.

on the deﬁnition of eligibility that is used) continued to exhibit behaviors that would exclude them from PTSD treatment. Consis- tent with hypotheses, BPD+PTSD clients who began treatment with a greater number of suicide attempts in the previous 4 months and more severe PTSD were less likely to eliminate the two deﬁnite exclusion criteria by posttreatment. These results parallel ﬁndings from PTSD treatment outcome research indicating that greater PTSD severity at baseline predicts worse outcomes (e.g., Taylor, 2004; van Minnen, Arntz, & Keijsers, 2002). However, in contrastto hypotheses, the remaining baseline characteristics did not dif- ferentiate between those BPD+PTSD clients who did and did not become eligible for PTSD treatment. Of particular note, clients whose index trauma occurred in childhood were just as likely to become appropriate for PTSD treatment as those whose index trauma occurred in adulthood. It is possible that the severity of the sample may have minimized the ability to ﬁnd differences given the low variability at pretreatment. Alternatively, the lack of signif- icant ﬁndings may be due to low power. However, these ﬁndings Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 428Harned et al.

are also consistent with previous research that has largely been unable to identify predictors of DBT treatment response (Bohus et al., 2004).

It is possible that, with a longer course of DBT, these BPD+PTSD clients may eventually eliminate these remaining exclusionary behaviors. However, it is also possible that some BPD+PTSD clients may be unable to eliminate behaviors that are commonly used as exclusion criteria for PTSD treatment, per- haps particularly as long as their PTSD continues to be active and untreated. Indeed, given research indicating that PTSD de- creases the likelihood of attaining remission from BPD (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006; Zanarini et al., 2004) and BPD criterion behaviors (e.g., nonsuicidal self-injury) may function to manage ﬂashbacks, dissociation, and other PTSD symptoms (Klonsky, 2007), it is possible that some BPD clients may be unable to stop these behaviors until their PTSD is re- solved. In such cases, it may be necessary to modify standard PTSD treatments to allow for clients to receive the treatment even if they continue to exhibit some potential exclusion criteria (e.g., by increasing monitoring and management of suicidality or in- corporating strategies for decreasing dissociation during treatment sessions). Further research is needed to identify how to treat these nonresponders more effectively during DBT and to develop meth- ods to safely make PTSD treatment available to them even if they do not meet standard deﬁnitions of readiness.

Finally, it is important to note that the exclusion criteria rec- ommended in the PE manual are clinically derived and have never been empirically examined. Thus, it is possible that clients who exhibit some of these behaviors may still be able to safely receive and beneﬁt from PTSD treatment. In addition, the PE inclu- sion/exclusion criteria were not developed speciﬁcally for BPD clients who often exhibit a variety of difﬁcult behaviors that might not be typical in other PTSD samples (e.g., intense hostility to- wards the therapist, extreme emotional avoidance) and such prob- lems may need to be stabilized before initiating a PTSD treatment.

Further research is needed to clarify empirically derived criteria for determining readiness for PTSD treatment in general, as well as speciﬁcally among BPD clients.

There are several limitations to the present study. First, we were unable to examine some of the exclusion criteria recommended in the PE manual because these constructs were not assessed in our data. 2Speciﬁcally, rates of current/ongoing assault (e.g., domestic violence), imminent threat of homicide, and insufﬁcient memory of the traumatic event(s) were not assessed. In addition, we de- ﬁned recent self-injury as occurring in the past 4 months (because assessments occurred at 4-month intervals), whereas the PE man- ual only excludes individuals with self-injury that occurred in the past 3 months. Second, we based our analyses on the PE exclusion 2Although not explicitly examined as an exclusion criterion in the present analyses, current psychotic disorder was used as an exclusion criterion in the larger RCT from which this sample was drawn. criteria given that exposure therapy is the most empirically sup- ported treatment for PTSD and PE is the most widely used and studied PTSD exposure treatment (Foa et al., 2009). However, other ways of deﬁning eligibility for PTSD treatment exist and may have resulted in different outcomes. Third, the present study utilized general diagnostic interviews to assess PTSD and did not include any PTSD-speciﬁc measures, which would have strength- ened the design. Finally, future research is needed to determine whether the present results generalize to samples of suicidal and/or self-injuring PTSD clients without BPD, men, and clients who are explicitly seeking PTSD treatment.

In sum, given the high rate of suicidal and self-injurious be- havior among individuals with PTSD and the common practice of excluding these clients from PTSD treatment, there currently exists a signiﬁcant population of individuals with PTSD who are unable to access PTSD treatment. Thus, there is a critical need to identify treatment strategies that will enable these clients to safely and effectively receive treatment for their PTSD. The present data suggest that DBT may be an effective treatment for stabilizing sui- cidal, self-injuring, and multiproblem PTSD clients who would otherwise be excluded from PTSD treatment.

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