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Randomized Controlled Trial
. 2024;15(1):2382652.
doi: 10.1080/20008066.2024.2382652. Epub 2024 Aug 1.

Trauma-focused and personality disorder treatment for posttraumatic stress disorder and comorbid cluster C personality disorder: a randomized clinical trial

Arne van den End  1   2 , Aartjan T F Beekman  1 , Jack Dekker  3   4 , Inga Aarts  2   5 , Aishah Snoek  1   2 , Matthijs Blankers  3 , Chris Vriend  1   5   6 , Odile A van den Heuvel  1   5   6 , Kathleen Thomaes  1   2   5
Affiliations
Randomized Controlled Trial

Trauma-focused and personality disorder treatment for posttraumatic stress disorder and comorbid cluster C personality disorder: a randomized clinical trial

Arne van den End et al. Eur J Psychotraumatol. 2024.

Abstract
in English, Spanish

Background: Posttraumatic stress disorder (PTSD) is associated with high rates of cluster C personality disorders (PD), which may negatively affect PTSD treatment. It is unknown whether concurrent treatment for PTSD and comorbid PD leads to superior treatment effects, compared to standard trauma-focused treatment.Objective: The objective was to test the efficacy of adding personality disorder treatment (group schema therapy; GST) to individual trauma-focused treatment (imagery rescripting; ImRs).Method: A two-arm randomized clinical trial (1:1 allocation ratio) was conducted between 2018 and 2023 at two sites of a mental health institution in the Netherlands. Raters were blind to treatment allocation. Adult outpatients with PTSD and comorbid cluster C personality disorders were randomized to receive either ImRs (12-18 sessions) or ImRs + GST (12-18 ImRs + 52-58 GST). The main outcome was PTSD severity one year after start of treatment measured with the Clinician-Administered PTSD Scale for DSM-5.Results: Of 130 patients (mean [SD] age = 40.6 [11.2], 110 [85%] females), 66 were assigned to ImRs and 64 to ImRs + GST. At 12 months, there were large decreases in PTSD severity (dImRs = 2.42, 95%CI = 1.97-2.87; dImRs + GST = 2.44, 95%CI = 1.99-2.90), but there was no significant difference between conditions (d = 0.02, 95%CI = -0.33-0.36, p = .944). Reductions in personality disorder symptoms and all other secondary outcomes were observed in both conditions. There were no significant differences between conditions on any of the secondary outcomes at 12 months.Conclusion: The more intensive concurrent trauma-focused and personality disorder treatment (ImRs + GST) was not superior to trauma-focused treatment alone (ImRs) for patients with PTSD and comorbid CPD. This suggests that trauma-focused treatment is the preferred primary treatment in patients presenting with both internalizing personality disorder and PTSD, reserving the stepping up to more intensive psychotherapy aimed at the personality disorder as a second line of treatment.Trial registration: ClinicalTrials.gov identifier: NCT03833531.

Antecedentes: El trastorno de estrés postraumático (TEPT) está asociado con altas tasas de trastornos de la personalidad (TP) del cluster C, lo que puede afectar negativamente el tratamiento del TEPT. Se desconoce si el tratamiento concurrente para el TEPT y el TP comórbido conduce a mejores resultados del tratamiento, en comparación con el tratamiento estándar centrado en el trauma.

Objetivo: El objetivo fue probar la eficacia de agregar un tratamiento para el trastorno de la personalidad (terapia de esquemas grupal; TEG) al tratamiento individual centrado en el trauma (reescritura de imágenes; RI).

Método: Se llevó a cabo un ensayo clínico aleatorizado de dos brazos (relación de asignación 1:1) entre 2018–2023 en dos sitios de una institución de salud mental en los Países Bajos. Los evaluadores desconocían la asignación del tratamiento. Los pacientes ambulatorios adultos con TEPT y trastornos de la personalidad del cluster C comórbidos fueron asignados aleatoriamente para recibir RI (12–18 sesiones) o RI + TEG (12–18 RI + 52–58 TEG). El resultado principal fue la gravedad del TEPT un año después del inicio del tratamiento, medida con la Escala de TEPT Administrada por el Clínico para el DSM-5.

Resultados: De 130 pacientes (edad media [DE] = 40,6 [11,2], 110 [85%] mujeres), 66 fueron asignados a RI y 64 a RI + TEG. A los 12 meses, hubo grandes disminuciones en la gravedad del TEPT (dRI = 2,42, IC del 95% = 1,97–2,87; dRI + TEG = 2,44, IC del 95% = 1,99–2,90), pero no hubo diferencias significativas entre las condiciones (d = 0,02, IC del 95% = −0,33–0,36, p = ,944). Se observaron reducciones en los síntomas del trastorno de la personalidad y en todos los demás resultados secundarios en ambas condiciones. No hubo diferencias significativas entre las condiciones en ninguno de los resultados secundarios a los 12 meses.

Conclusión: El tratamiento concurrente más intensivo centrado en el trauma y el trastorno de la personalidad (RI + TEG) no fue superior al tratamiento centrado sólo en el trauma (RI) para pacientes con TEPT y TPC comórbido. Esto sugiere que el tratamiento centrado en el trauma es el tratamiento primario de referencia en pacientes que presentan tanto trastorno de la personalidad internalizante como TEPT, reservando la intensificación a una psicoterapia más intensiva dirigida al trastorno de la personalidad como segunda línea de tratamiento.

Keywords: PTSD; TEPT; avoidant; cluster C; evitación; imagery rescripting; obsesivo-compulsivo; obsessive-compulsive; personality disorder; reescritura de imágenes; schema therapy; terapia de esquemas; trastorno de personalidad.

Plain language summary

Concurrent trauma-focused and personality disorder treatment was not superior to only trauma-focused treatment for patients with posttraumatic stress disorder (PTSD) and comorbid cluster C personality disorders.Large reductions in PTSD severity and medium-to-large reductions in all secondary outcomes, including personality disorder symptoms, were observed in both treatment arms.These findings are remarkable, given the higher therapy dosage and specialized treatment for personality disorder comorbidity in the combined treatment arm.

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Conflict of interest statement

No potential conflict of interest was reported by the author(s).

Figures

Figure 1.
Figure 1.
CONSORT flowchart. Abbreviation: ImRs = imagery rescripting; ST = schema therapy; CAPS-5 = Clinician-Administered PTSD Scale for DSM-5; T2 = post-ImRs; T4 = 6-months post-ImRs.
Figure 2.
Figure 2.
Changes over time per condition in primary and key secondary outcomes. Changes in clinician-rated CAPS-5 total scores are displayed on the left. Self-reported PCL-5 total scores and SCID-5-PD CPD symptom scores over time are displayed on the right. Estimated marginal means were calculated from the pooled estimates after multiple imputation. Error bars show 95%CIs calculated from the estimated marginal means. Abbreviation: CAPS-5 = Clinician-administered PTSD Scale for DSM-5; ImRs = imagery rescripting; ImRs + GST = imagery rescripting with group schema therapy and psychomotor therapy; PCL-5 = PTSD checklist – DSM-5; SCID-5-PD = Structured Clinical Interview for DSM-5 Personality Disorders; CPD = cluster C personality disorder.
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