Eye Movement Desensitization and Reprocessing Therapy in Persons With Personality Disorders - A Randomized Clinical Trial (Eye Movement Desensitization and Reprocessing Therapy in Persons With Personality Disorders - A Randomized Clinical Trial)

Authors: Simon Hofman, MSc; Laurian Hafkemeijer, MSc; Ad de Jongh, PhD; Cristina W. Slotema, PhD
Published: September 25, 2025.  doi:10.1001/jamanetworkopen.2025.33421
Translated by: Specialist Psychologist Elena Gizem Pozam

Key Points

Question: Does eye movement desensitization and reprocessing (EMDR) therapy reduce personality disorder (PD) symptoms, regardless of posttraumatic stress disorder status?

Findings: In this randomized clinical trial involving 159 participants with personality disorders, EMDR therapy was superior to a waiting list control group in reducing PD symptoms at posttreatment and follow-up. PD remission was significantly more common in the EMDR group than in the control group at both time points.

Meaning: In this study, EMDR therapy demonstrated clinically meaningful reductions in PD symptoms, and nearly half of the participants achieved diagnostic remission, supporting its potential as an effective intervention for PDs.

Abstract

Importance: Adverse childhood experiences contribute to the development of personality disorders (PDs). Although trauma-focused interventions are effective for posttraumatic stress disorder (PTSD), their effects on PD symptoms are less well established.

Objective: To evaluate the effectiveness of eye movement desensitization and reprocessing (EMDR) therapy compared with a waiting list in reducing PD symptoms, regardless of posttraumatic stress disorder status.

Design, Setting, and Participants: This 2-arm, multicenter, single-blind, randomized clinical trial was conducted in specialized outpatient departments at 2 clinics in the Netherlands between February 22, 2021, and October 2, 2024. Participants included 159 individuals with PDs diagnosed using the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD). Data were analyzed according to the intention-to-treat principle.

Intervention: Ten 90-minute EMDR sessions over 5 weeks targeting traumatic and adverse memories associated with PD symptoms.

Main Outcomes and Measures: Pretreatment, posttreatment, and 3-month follow-up assessments were conducted using the Assessment of DSM-IV Personality Disorders (ADP-IV), SCID-5-PD, Level of Personality Functioning Scale (LPFS), and Difficulties in Emotion Regulation Scale (DERS).

Results: The 159 clients included in the analysis had a mean (SD) age of 35.4 (12.0) years, and 130 were women (81.8%). Seventy-nine participants were randomized to the EMDR group and 80 to the waiting list control group. Four participants (5.1%) dropped out of the EMDR group, and 16 participants (20.3%) completed treatment early without any adverse events. EMDR therapy outperformed the waiting list condition on the ADP-IV at posttreatment (β, −37.93 [95% CI, −52.54 to −23.33]; P < .001; Cohen d = 0.31 [95% CI, −0.05 to 0.66]) and follow-up (β, −45.73 [95% CI, −64.90 to −26.56]; P < .001; Cohen d = 0.46 [95% CI, 0.10-0.82]), on the SCID-5-PD at posttreatment (β, −3.65 [95% CI, −5.87 to −1.42]; P = .002; d = 0.48 [95% CI, 0.14-0.82]) and follow-up (β, −3.70 [95% CI, −7.10 to −0.30]; P = .03; Cohen d = 0.61 [95% CI, 0.25-0.97]), on the LPFS at posttreatment (β, −3.13 [95% CI, −4.86 to −1.41]; P < .001; Cohen d = 0.31 [95% CI, −0.05 to 0.67]) and follow-up (β, −3.62 [95% CI, −5.96 to −1.28]; P = .003; Cohen d = 0.43 [95% CI, 0.06-0.79]), and on the DERS at posttreatment (β, −9.03 [95% CI, −14.90 to −3.15]; P = .003; Cohen d = 0.35 [95% CI, −0.01 to 0.71]) and follow-up (β, −11.73 [95% CI, −19.90 to −3.55]; P = .005; Cohen d = 0.62 [95% CI, 0.25-0.98]). PD remission was more common in the EMDR group than in the control groups at both posttreatment (ADP-IV, 38.3% vs 6.8%; SCID-5-PD, 33.3% vs 7.8%) and follow-up (ADP-IV, 45.4% vs 5.9%; SCID-5-PD, 44.1% vs 15.8%).

Conclusions and Relevance: In this randomized clinical trial involving 159 clients with PDs, EMDR therapy led to significant reductions in PD symptoms, and 30 individuals (44.1%) achieved remission. These findings support the potential of EMDR therapy for treating PDs and encourage further confirmatory research.

Introduction

Personality disorders (PDs) are a major public health concern, affecting approximately 12% of the general population¹ and up to 50% of individuals in psychiatric outpatient settings.² PDs cause substantial difficulties for individuals and affect their families and communities, contributing to considerable societal costs.³,⁴ Although psychotherapy is an effective first-line treatment, it typically requires a long-term commitment, often exceeding 1 year, at least for individuals with clinical or subclinical borderline PD.⁵

Given the association between adverse childhood experiences and the development of PDs,⁶,⁷ trauma-focused therapy has attracted attention as a potential treatment for PDs.⁸ Research shows that trauma-focused therapies significantly reduce PTSD symptoms in clients with co-occurring borderline PD and PTSD (Hedges g range, 1.04-1.31) and are associated with minimal adverse events.⁹,¹⁰ Furthermore, treating PTSD in clients with co-occurring PDs appears to be safe and effective (Hedges g = 0.52),⁹ with adverse events reported infrequently and with minimal severity.¹¹⁻¹⁵

Eye movement desensitization and reprocessing (EMDR) therapy is an established treatment for processing traumatic memories¹⁶⁻¹⁸ and has shown promise in reducing psychological distress and improving functioning in individuals with PDs, even without co-occurring PTSD.¹⁹ A randomized clinical trial in clients with PDs without co-occurring PTSD⁸,¹⁹⁻²¹ showed that 5 EMDR sessions targeting adverse childhood experiences, such as emotional abuse or neglect, led to moderate reductions on the Brief Symptom Inventory (Cohen d = 0.65) and improvements in personality functioning (Cohen d = 0.56), with no adverse events and less symptom exacerbation than in the waiting list control group. That study did not assess PD symptom severity, diagnostic remission, or the severity of emotion dysregulation and administered only 5 weekly EMDR sessions.

To address these gaps and advance the development of a brief and effective therapeutic approach for PDs, this study investigated the effectiveness of EMDR therapy for PDs, regardless of the presence of PTSD. The primary objective was to determine whether EMDR therapy could significantly reduce PD symptoms compared with a waiting list control condition. We hypothesized that EMDR therapy would lead to a significant reduction in PD symptom severity compared with the control condition. Secondary objectives included evaluating diagnostic remission, changes in personality functioning, and difficulties in emotion regulation.

Methods

Design

This study was part of a multicenter, single-blind, superiority randomized clinical trial comparing EMDR therapy with a waiting list control condition (1:1) (the Effect of Trauma-Focused EMDR on Outpatients With PDs study). The trial protocol (Supplement 1) adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines, was approved by the Medical Research Ethics Committee of Erasmus Medical Center in Rotterdam, and has been published previously.²² All participants provided written informed consent.

Participants

A total of 159 participants were recruited from outpatient clinics at 2 mental health institutions in the Netherlands: Parnassia Psychiatric Institute in The Hague and GGZ Delfland in Delft. Eligible participants had to be aged 18 years or older and diagnosed with any PD using the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD).²³ Clients diagnosed with other specified PD had to exhibit at least 10 PD symptoms. Exclusion criteria were insufficient proficiency in Dutch or an estimated IQ below 70. A power analysis²² determined that a total sample of 132 participants was required to detect a treatment effect on PD symptom severity using linear mixed models, assuming an effect size of Cohen d = 0.43, a correlation of 0.70 between repeated measures, α = .05, and power of 0.80. Accounting for 20% missing data, the final sample size was 159 participants.

Measures

Assessments were conducted at baseline, posttreatment, and 3-month follow-up. Assessors (including S.H.) attended standardized external training sessions to ensure consistency in administering structured interviews. All outcome assessments were performed blind to treatment allocation, and assessors were not involved in treatment. The primary measure was the Assessment of DSM-IV Personality Disorders (ADP-IV), which provides a total severity score and allows a categorical PD diagnosis.²⁴ Secondary measures included the SCID-5-PD,²³ a semistructured interview used to assess DSM-5 PDs; the Level of Personality Functioning Scale–Brief Form 2.0 (LPFS),²⁵,²⁶ which assesses personality functioning based on the alternative DSM-5 model for PDs; and the Difficulties in Emotion Regulation Scale (DERS),²⁷ a self-report questionnaire developed to measure clinically relevant difficulties in emotion regulation. Hofman and colleagues²² provide a description of the design and an overview of the measures.

Procedure

Recruitment for this study took place between February 22, 2021, and April 9, 2024, and data collection was completed on October 3, 2024. Participants were recruited through multiple channels: (1) posters in outpatient clinic waiting rooms, (2) direct referrals by therapists, and (3) proactive outreach to clients who had consented to being contacted by researchers for research purposes. Recruitment emphasized that individuals with any PD could participate, regardless of the presence of PTSD or traumatic memories. Interested individuals received detailed study information and were screened for eligibility by the research team before providing informed consent. Randomization was performed using a pregenerated random sequence (1:1 allocation without blocks) generated in the ResearchManager electronic data capture system, an independent external platform used for secure data management. Allocation was concealed from blinded researchers, with only unblinded researchers (including S.H. and L.H.) and the principal investigator (C.W.S.) able to access allocation through a restricted interface; details of the process are available from Hofman and colleagues.²² Participants in the waiting list condition did not receive any trauma-focused or PD treatment, and their medication regimens remained unchanged, although interim contact was available if needed. For all participants, the therapist who conducted the initial diagnostic assessment met with the participant after the 3-month follow-up to determine whether further treatment was necessary.

Treatment

Half of the participants received 10 EMDR sessions, each lasting 90 minutes, administered twice weekly over 5 weeks. Treatment followed a structured case conceptualization.⁷ Sessions initially targeted traumatic memories meeting PTSD criterion A,²⁵ prioritizing intrusive memories before moving on to nonintrusive memories. Therapy focused on memories associated with the client's most prominent PD symptoms. The standard EMDR protocol²⁸ was used, while EMDR 2.0 incorporated a higher working memory load.²⁹ Anticipatory fear that interfered with treatment was addressed using the flashforward protocol.³⁰ Participants who no longer met the diagnostic criteria for a PD during treatment, based on their ADP-IV score, were defined as early completers.

Supervision and Fidelity Monitoring

EMDR therapy was delivered by certified therapists who had completed an accredited Dutch-language basic EMDR training program. Before the study, all therapists attended an additional 1-day training delivered by an EMDR Europe Association (EMDREA)–approved trainer. Therapists reported each case conceptualization and EMDR session to an EMDREA-approved consultant using a custom-designed form that included details about target memories and their subjective units of distress levels before and after the therapy session, the time spent fully reprocessing memories, and overall session summaries. Monthly group supervision was provided by EMDREA-approved consultants, with video recordings of EMDR sessions presented. Additional supervision was available on request. All sessions were video-recorded, and 1 session was randomly selected for 20% of participants and rated by trained assessors blinded to treatment outcomes. Protocol adherence was high, with a score of 9.8 out of 11 (89.5%); 100% of sessions scored at least 8.

Statistical Analysis

Data were analyzed using SPSS, version 27 (IBM Corporation), and R, version 4.3.3, with the nlme and lme4 packages (R Statistical Computing Program). Primary and secondary outcomes were analyzed using linear mixed models (LMMs). Each model included fixed effects for group (EMDR vs control), time (baseline, posttreatment, and follow-up), their interaction, and baseline severity, as well as a random intercept for participants and a random slope for time. Models were estimated using restricted maximum likelihood with an autoregressive covariance structure to account for temporal correlations between repeated measures. This approach incorporates all available data under the missing-at-random assumption and ensures the inclusion of all randomized participants in accordance with the intention-to-treat principle.

To aid interpretation, within-group and between-group Cohen d effect sizes were reported for descriptive purposes only. Within-group effect sizes reflect the magnitude of change over time within each condition, while between-group effect sizes at posttreatment and follow-up indicate the magnitude of group differences at those time points. Cohen d was calculated by dividing the mean difference (within or between groups) by the pooled standard deviation. Effect sizes were categorized as small (0.20), medium (0.50), or large (0.80). A two-tailed significance level of d = .05 was applied to all inferential tests.

Generalized LMMs (GLLMs) were used to test whether PD remission according to the ADP-IV was more common in the EMDR group than in the control group. In addition to the interaction term (group × time), all models included the main effects of group (2 levels: EMDR vs control) and time (3 levels: baseline, posttreatment, and follow-up), and a random effect controlling for within-participant variance. Because a SCID-5-PD diagnosis was required for inclusion, all participants (100%) had a PD at baseline, which prevented convergence of the GLMMs. Therefore, to compare PD remission based on the SCID-5-PD, χ2  tests were conducted at posttreatment and 3-month follow-up with group (2 levels: EMDR vs control) and PD diagnosis (2 levels: yes vs no), with a Bonferroni correction applied for multiple testing. Odds ratios (ORs) were calculated to quantify the effect size.

Sensitivity analyses were conducted to examine the robustness of the findings; these included completers-only analyses (SCID-5-PD, 122; ADP-IV, 113; LPFS, 107; and DERS, 107) and multiple imputation (MI) using the mice package³¹ in R, version 4.3.3. MI generated 35 datasets over 50 iterations, accounting for the multilevel data structure.³² Estimates and standard errors were pooled using Rubin's rules.

Results

As shown in the Figure, 159 participants (mean age, 35.4 [12.0] years; 130 women [81.8%] and 29 men [18.2%]) were randomly assigned to either EMDR therapy (n = 79) or the waiting list control group (n = 80). Outcome data were available for 137 participants (86.2%) at posttreatment and 127 participants (79.9%) at follow-up. Table 1 presents baseline demographic and clinical characteristics, which were well balanced between groups.

Of the 79 EMDR participants, 4 (5.1%) dropped out of therapy. No adverse events were reported. A total of 25 participants (31.6%) fully processed all targeted memories before completing all EMDR sessions. Of these, 16 participants (20.3%) no longer met the diagnostic criteria for a PD according to the ADP-IV and were classified as early completers. In total, 25 participants (15.7%) deviated from the medication stabilization protocol. These deviations were evenly distributed between the EMDR (13 [16.5%]) and control (12 [15.0%]) groups.

Intention-to-Treat Analyses

The LMMs revealed significant group × time interaction effects across all primary and secondary outcomes (Table 2), indicating greater improvements in PD symptom severity, personality functioning, and emotion regulation in the EMDR group than in the control group. Specifically, EMDR therapy outperformed the waiting list on the ADP-IV at posttreatment (β, −37.93 [95% CI, −52.54 to −23.33]; P < .001; Cohen d = 0.31 [95% CI, −0.05 to 0.66]) and follow-up (β, −45.73 [95% CI, −64.90 to −26.56]; P < .001; Cohen d = 0.46 [95% CI, 0.10-0.82]), on the SCID-5-PD at posttreatment (β, −3.65 [95% CI, −5.87 to −1.42]; P = .002; Cohen d = 0.48 [95% CI, 0.14-0.82]) and follow-up (β, −3.70 [95% CI, −7.10 to −0.30]; P = .03; Cohen d = 0.61 [95% CI, 0.25-0.97]), on the LPFS at posttreatment (β, −3.13 [95% CI, −4.86 to −1.41]; P < .001; Cohen d = 0.31 [95% CI, −0.05 to 0.67]) and follow-up (β, −3.62 [95% CI, −5.96 to −1.28]; P = .003; Cohen d = 0.43 [95% CI, 0.06-0.79]), and on the DERS at posttreatment (β, −9.03 [95% CI, −14.90 to −3.15]; P = .003; Cohen d = 0.35 [95% CI, −0.01 to 0.71]) and follow-up (β, −11.73 [95% CI, −19.90 to −3.55]; P = .005; Cohen d = 0.62 [95% CI, 0.25-0.98]). Completers-only sensitivity analyses showed similar results. Site differences were found not to affect treatment outcomes, as indicated by model comparisons (χ2<0.01 for all; P = .99]) and interaction tests.

The initial MI yielded consistent model estimates (β coefficients) compared with the primary analyses. However, reduced degrees of freedom in MI led to lower power and higher P values, likely attributable to a subset of participants with baseline data only (n = 19) (primarily from the control group), EMDR dropouts (n = 4), and 1 early completer. This pattern suggests that the data may have been missing not at random rather than missing at random. A second MI excluding these 19 cases (n = 140) produced estimates, degrees of freedom, and P values closely aligned with the primary analyses, supporting the robustness of the findings.

Between-group effect sizes were small at posttreatment (Cohen d = 0.31-0.48) and ranged from small to medium at follow-up (Cohen d = 0.43-0.62) (Table 2). Within the EMDR group, improvements from baseline to posttreatment ranged from small to medium (Cohen d = 0.45-0.76), increasing to medium to large from baseline to follow-up (Cohen d = 0.76-0.98) (Table 2). Within the EMDR group, effect sizes ranged from small to large across diagnostic subgroups, but generally indicated consistent benefits across different PDs (Table 3).

A GLLM revealed a significant group × time interaction, with a greater reduction in ADP-IV diagnoses in the EMDR group than in the control group from baseline to posttreatment (38.3% vs 6.8%; β = −2.27 [95% CI, −3.81 to −0.73]; P = .003; OR, 0.10 [95% CI, 0.02-0.47]) and from baseline to 3-month follow-up (45.4% vs 5.9%; β = −2.90 [95% CI, −4.51 to −1.29]; P < .001; OR, 0.06 [95% CI, 0.01-0.27]). SCID-5-PD diagnoses also decreased more in the EMDR group than in the control group at both posttreatment (24 [33.3%] vs 5 [7.8%]; χ21 = 11.68 ; P < .001; OR, 0.17 [95% CI, 0.06-0.48]) and follow-up (30 [44.1%] vs 9 [15.8%]; χ21, = 10.31 ; P = .001; OR, 0.24 [95% CI, 0.10-0.56]) (Table 4). Completers-only sensitivity analyses showed similar results.

 

Discussion

This randomized clinical trial evaluated the effectiveness of stand-alone EMDR therapy for treating PDs, regardless of co-occurring PTSD, compared with a waiting list control condition. The results showed significant reductions in PD symptom severity at posttreatment and 3-month follow-up, with 44.1% of participants achieving diagnostic remission, along with improvements in personality functioning and emotion regulation. These effects were consistent across PD subtypes and among clients with and without a PTSD diagnosis at baseline. The dropout rate was low (4 [5.1%]), and no adverse events were reported.

These findings contribute to the growing body of evidence⁹,¹¹ supporting trauma-focused interventions for treating PDs, including stand-alone approaches.¹²⁻¹⁵ The results are consistent with an earlier study⁸ showing that trauma-focused therapy can be effective in PD populations even in the absence of PTSD. This study extends the literature by systematically examining PD symptom severity, diagnostic remission, and emotion dysregulation, providing strong evidence for the safe and effective use of EMDR therapy as a stand-alone intervention for PDs, regardless of co-occurring PTSD. Although previous studies⁷,⁹,¹⁰ have primarily focused on treating borderline PD and have often used long-term psychotherapeutic interventions, this study suggests that targeting memories of traumatic and adverse events through EMDR may yield clinically meaningful improvements across a range of PDs. The results align with theoretical models that conceptualize maladaptive personality traits as arising from unresolved traumatic experiences and reinforce the emerging view that trauma-focused therapies may be beneficial beyond traditional PTSD populations.⁷

Recommendations

These findings suggest that EMDR therapy may serve as a useful starting point for treating PDs, particularly given the substantial reductions in PD symptom severity and diagnostic status observed after a brief intervention. Given the continued improvement at follow-up, it may be appropriate to reassess the need for additional treatment 3 months after therapy. Some clients may benefit sufficiently from EMDR therapy alone, while others may require further interventions. Future research should evaluate the long-term effects of EMDR and compare them with active controls, such as standard PD treatments and alternative trauma-focused treatments. This could help clarify the specific contribution of EMDR therapy and reduce potential expectancy effects. To maximize therapeutic outcomes, the optimal delivery of EMDR therapy should be investigated by examining variables such as the number, frequency, and timing of sessions.

 

Strengths and Limitations

Strengths

This study has several strengths, including high retention rates, the use of both dimensional and categorical assessments of PDs, the inclusion of individuals with and without PTSD, and the representation of a broad range of PDs, including less-studied types such as assertive and other specified PDs, enhancing the ecological validity of the findings. The effect sizes provided quantitative benchmarks for comparison with previous research.

Limitations

Several limitations should also be noted. First, a waiting list control condition not only restricts the ability to attribute treatment effects specifically to EMDR therapy but also limits the ability to estimate the true effect size. Recent meta-analytic evidence from depression research³³ indicates that studies using waiting list control groups tend to yield inflated effect sizes compared with those using active treatment controls, largely because of the smaller pre-post changes observed in the waiting list conditions themselves. In addition, using a waiting list group may create expectancy effects because participants know they will eventually receive the intervention, potentially reducing the observed differences between groups. Nevertheless, we agree that future studies in this area should aim to include active or usual-care control conditions to enhance the internal and external validity of the findings. Second, double-blinding (e.g., sham EMDR) was not possible, potentially leading to expectancy effects. Third, the control group also showed significant improvements over time, likely reflecting the effect of study participation itself. Fourth, although the diagnostic instruments used in this study (i.e., ADP-IV and SCID-5-PD) were designed to assess enduring personality pathology, the 3-month follow-up remains a relatively short period for assessing sustained change. Fifth, although the sample included a broad range of PD types, most participants had avoidant, borderline, obsessive-compulsive, or other specified PDs, limiting generalizability to less common PD types. Finally, although benefits persisted for at least 3 months, long-term effects remain unknown.

Conclusions

This randomized clinical trial supports the potential of trauma-focused approaches such as EMDR therapy for treating PD pathology. Further research is needed to confirm and extend these results, including head-to-head comparisons with established psychotherapeutic interventions for PDs.

References

1. Volkert J, Gablonski TC, Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. Br J Psychiatry. 2018;213(6):709-715. doi:10.1192/bjp.2018.202


2. Beckwith H, Moran PF, Reilly J. Personality disorder prevalence in psychiatric outpatients: a systematic literature review. Personal Ment Health. 2014;8(2):91-101. doi:10.1002/pmh.1252


3. Samuels J. Personality disorders: epidemiology and public health issues. Int Rev Psychiatry. 2011;23(3):223-233. doi:10.3109/09540261.2011.588200


4. Soeteman DI, Hakkaart-van Roijen L, Verheul R, Busschbach JJ. The economic burden of personality disorders in mental health care. J Clin Psychiatry. 2008;69(2):259-265. doi:10.4088/JCP.v69n0212


5. Setkowski K, Palantza C, van Ballegooijen W, et al. Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? a systematic review and network meta-analysis. Psychol Med. 2023;53(8):3261-3280. doi:10.1017/S0033291723000685


6. Broekhof R, Nordahl HM, Eikenæs IU, Selvik SG. Adverse childhood experiences are associated with personality disorder: a prospective, longitudinal study. J Pers Disord. 2024;38(1):19-33. doi:10.1521/pedi.2024.38.1.19


7. De Jongh A, Hafkemeijer L, Hofman S, Slotema K, Hornsveld H. The AIP model as a theoretical framework for the treatment of personality disorders with EMDR therapy. Front Psychiatry. 2024;15:1331876. doi:10.3389/fpsyt.2024.1331876


8. Hafkemeijer L, de Jongh A, van der Palen J, Starrenburg A. Eye movement desensitization and reprocessing (EMDR) in patients with a personality disorder. Eur J Psychotraumatol. 2020;11(1):1838777. doi:10.1080/20008198.2020.1838777


9. Slotema CW, Wilhelmus B, Arends LR, Franken IHA. Psychotherapy for posttraumatic stress disorder in patients with borderline personality disorder: a systematic review and meta-analysis of its efficacy and safety. Eur J Psychotraumatol. 2020;11(1):1796188. doi:10.1080/20008198.2020.1796188


10. Snoek A, Nederstigt J, Ciharova M, et al. Impact of comorbid personality disorders on psychotherapy for post-traumatic stress disorder: systematic review and meta-analysis. Eur J Psychotraumatol. 2021;12(1):1929753. doi:10.1080/20008198.2021.1929753


11. Kolthof KA, Voorendonk EM, Van Minnen A, De Jongh A. Effects of intensive trauma-focused treatment of individuals with both post-traumatic stress disorder and borderline personality disorder. Eur J Psychotraumatol. 2022;13(2):2143076. doi:10.1080/20008066.2022.2143076


12. Markowitz JC, Petkova E, Biyanova T, Ding K, Suh EJ, Neria Y. Exploring personality diagnosis stability following acute psychotherapy for chronic posttraumatic stress disorder. Depress Anxiety. 2015;32(12):919-926. doi:10.1002/da.22436


13. Snoek AC, van den End A, Beekman ATF, et al. Eye movement desensitization and reprocessing with and without dialectical behavior therapy for posttraumatic stress disorder and comorbid borderline personality disorder symptoms: a randomized controlled trial. Psychother Psychosom. 2025;94(3):175-193. doi:10.1159/000544918


14. Steuwe C, Berg M, Beblo T, Driessen M. Narrative exposure therapy in patients with posttraumatic stress disorder and borderline personality disorder in a naturalistic residential setting: a randomized controlled trial. Front Psychiatry. 2021;12:765348. doi:10.3389/fpsyt.2021.765348


15. van den End A, Beekman ATF, Dekker J, et al. Trauma-focused and personality disorder treatment for posttraumatic stress disorder and comorbid cluster C personality disorder: a randomized clinical trial. Eur J Psychotraumatol. 2024;15(1):2382652. doi:10.1080/20008066.2024.2382652


16. de Jongh A, de Roos C, El-Leithy S. State of the science: eye movement desensitization and reprocessing (EMDR) therapy. J Trauma Stress. 2024;37(2):205-216. doi:10.1002/jts.23012


17. Mavranezouli I, Megnin-Viggars O, Grey N, et al. Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults. PLoS One. 2020;15(4):e0232245. doi:10.1371/journal.pone.0232245


18. U.S. Department of Veterans Affairs and the Department of Defense. VA/DoD Clinical Practice Guideline: Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 2023. Accessed May 1, 2025. https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp


19. Hafkemeijer L, Starrenburg A, van der Palen J, Slotema K, de Jongh A. Does EMDR therapy have an effect on memories of emotional abuse, neglect and other types of adverse events in patients with a personality disorder? preliminary data. J Clin Med. 2021;10(19):4333. doi:10.3390/jcm10194333


20. Hafkemeijer L, Slotema K, de Haard N, de Jongh A. Case report: brief, intensive EMDR therapy for borderline personality disorder: results of two case studies with one year follow-up. Front Psychiatry. 2023;14:1283145. doi:10.3389/fpsyt.2023.1283145


21. Hafkemeijer L, de Jongh A, Starrenburg A, Hoekstra T, Slotema K. EMDR treatment in patients with personality disorders: should we fear symptom exacerbation? Eur J Psychotraumatol. 2024;15(1):2407222. doi:10.1080/20008066.2024.2407222


22. Hofman S, Hafkemeijer L, de Jongh A, Starrenburg A, Slotema K. Trauma-focused EMDR for Personality disorders among Outpatients (TEMPO): study protocol for a multi-centre, single-blind, randomized controlled trial. Trials. 2022;23(1):196. doi:10.1186/s13063-022-06082-6


23. First MB. Structured Clinical Interview for the DSM (SCID). In: Cautin RL, Lilienfeld SO, eds. The Encyclopedia of Clinical Psychology. Wiley Blackwell; January 23, 2015.


24. Schotte CKW, de Doncker D, Vankerckhoven C, Vertommen H, Cosyns P. Self-report assessment of the DSM-IV personality disorders: measurement of trait and distress characteristics: the ADP-IV. Psychol Med. 1998;28(5):1179-1188. doi:10.1017/S0033291798007041


25. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013, .


26. Hutsebaut J, Feenstra DJ, Kamphuis JH. Development and preliminary psychometric evaluation of a brief self-report questionnaire for the assessment of the DSM–5 level of Personality Functioning Scale: the LPFS Brief Form (LPFS-BF). Personal Disord. 2016;7(2):192-197. doi:10.1037/per0000159


27. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav Assess. 2004;26(1):41-54. doi:10.1023/B:JOBA.0000007455.08539.94


28. Shapiro F. Eye movement desensitization and reprocessing therapy (EMDR). In: Landolt MA, Cloitre M, Schnyder U, eds. Evidence-Based Treatments for Trauma Related Disorders in Children and Adolescents. Springer; 2018:273-297.


29. Matthijssen SJMA, Brouwers T, van Roozendaal C, Vuister T, de Jongh A. The effect of EMDR versus EMDR 2.0 on emotionality and vividness of aversive memories in a non-clinical sample. Eur J Psychotraumatol. 2021;12(1):1956793. doi:10.1080/20008198.2021.1956793


30. Logie RDJ, De Jongh A. The “flashforward procedure”: confronting the catastrophe. J EMDR Pract Res. 2014;8(1):25-32. doi:10.1891/1933-3196.8.1.25


31. van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate imputation by chained equations in R. J Stat Softw. 2011;45(3):1-67. doi:10.18637/jss.v045.i03


32. Van Buuren S. Multiple imputation of multilevel data. In: Hox J, Roberts JK. Handbook of Advanced Multilevel Analysis. Routlege; 2011:173-196.


33. Cuijpers P, Miguel C, Harrer M, Ciharova M, Karyotaki E. The overestimation of the effect sizes of psychotherapies for depression in waitlist controlled trials: a meta-analytic comparison with usual care controlled trials. Epidemiol Psychiatr Sci. 2024;33:e56. doi:10.1017/S2045796024000611